Healthcare Provider Details

I. General information

NPI: 1851763650
Provider Name (Legal Business Name): KEELIN ELIZABETH COVACHA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 MENDON RD
CUMBERLAND RI
02864-3805
US

IV. Provider business mailing address

200 HEROUX BLVD UNIT 1606
CUMBERLAND RI
02864-2388
US

V. Phone/Fax

Practice location:
  • Phone: 401-333-5201
  • Fax:
Mailing address:
  • Phone: 203-829-8504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3454
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00922
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: