Healthcare Provider Details

I. General information

NPI: 1124520952
Provider Name (Legal Business Name): MARIA CHRISTINE BOTSKO BRENNAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA CHRISTINE BOTKO

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 ATWOOD AVE STE 220
JOHNSTON RI
02919-3289
US

IV. Provider business mailing address

1526 ATWOOD AVE STE 220
JOHNSTON RI
02919-3289
US

V. Phone/Fax

Practice location:
  • Phone: 401-404-2975
  • Fax: 401-404-2976
Mailing address:
  • Phone: 401-404-2975
  • Fax: 401-404-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01024
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01024
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: