Healthcare Provider Details

I. General information

NPI: 1306879242
Provider Name (Legal Business Name): RICHARD A ST. DENNIS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RICHARD A ST. DENNIS PA

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WOODLAND DR
COVENTRY RI
02816-6716
US

IV. Provider business mailing address

PO BOX 62939
BALTIMORE MD
21264-1551
US

V. Phone/Fax

Practice location:
  • Phone: 401-826-2000
  • Fax:
Mailing address:
  • Phone: 859-291-4800
  • Fax: 833-694-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001203
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00503
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: