Healthcare Provider Details

I. General information

NPI: 1013528199
Provider Name (Legal Business Name): MICHAEL GUNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 COMMERCE WAY STE 5
JOHNSTON RI
02919-4613
US

IV. Provider business mailing address

1130 TEN ROD RD STE E305
NORTH KINGSTOWN RI
02852-4176
US

V. Phone/Fax

Practice location:
  • Phone: 401-606-2610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01266
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPA01266
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: