Healthcare Provider Details

I. General information

NPI: 1235789231
Provider Name (Legal Business Name): MAXWELL HOGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL
RIVERSIDE RI
02915-2232
US

IV. Provider business mailing address

619 BOSTON NECK RD
NORTH KINGSTOWN RI
02852-6235
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4020
  • Fax: 401-649-4021
Mailing address:
  • Phone: 603-667-6765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2313022
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN02399
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: