Healthcare Provider Details

I. General information

NPI: 1104819341
Provider Name (Legal Business Name): ROBYN M OSTAPOW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 CORLISS ST STE B
PROVIDENCE RI
02904-2602
US

IV. Provider business mailing address

180 CORLISS ST STE B
PROVIDENCE RI
02904-2602
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8400
  • Fax: 401-793-8402
Mailing address:
  • Phone: 401-793-8400
  • Fax: 401-793-8402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA101298
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00380
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: