Healthcare Provider Details

I. General information

NPI: 1316672074
Provider Name (Legal Business Name): JOHN WILLIAM HURLEY JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

IV. Provider business mailing address

68 FARNUM PIKE
SMITHFIELD RI
02917-3224
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2000
  • Fax:
Mailing address:
  • Phone: 401-300-6559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: