Healthcare Provider Details

I. General information

NPI: 1033117825
Provider Name (Legal Business Name): PISCATAQUA PLASTIC SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BORTHWICK AVE STE 206
PORTSMOUTH NH
03801-4174
US

IV. Provider business mailing address

340 MAIN ST STE 670
WORCESTER MA
01608-1604
US

V. Phone/Fax

Practice location:
  • Phone: 603-431-5488
  • Fax: 603-431-4680
Mailing address:
  • Phone: 508-754-3566
  • Fax: 508-798-8012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateHI

VIII. Authorized Official

Name: CHARLES J GAUDET
Title or Position: PRESIDENT
Credential: M.D.
Phone: 603-431-5488