Healthcare Provider Details

I. General information

NPI: 1528065430
Provider Name (Legal Business Name): SANDRA M JAMIESON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET GRAD DORMS
PROVIDENCE RI
02903
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4038
  • Fax: 401-444-7074
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00121
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: