Healthcare Provider Details

I. General information

NPI: 1790493732
Provider Name (Legal Business Name): NATHAN VIOLETTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BULLOCKS POINT AVE
RIVERSIDE RI
02915-5351
US

IV. Provider business mailing address

100 BULLOCKS POINT AVE
RIVERSIDE RI
02915-5351
US

V. Phone/Fax

Practice location:
  • Phone: 401-437-1008
  • Fax:
Mailing address:
  • Phone: 401-437-1008
  • Fax: 401-433-3042

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: