Healthcare Provider Details

I. General information

NPI: 1083280556
Provider Name (Legal Business Name): FALLON D GUIN PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 BLACKSTONE BLVD
PROVIDENCE RI
02906-4800
US

IV. Provider business mailing address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-680-6502
  • Fax: 401-680-4128
Mailing address:
  • Phone: 401-737-7010
  • Fax: 401-736-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01329
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: