Healthcare Provider Details

I. General information

NPI: 1740028349
Provider Name (Legal Business Name): EMILY PETERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 SANDERSON RD STE 103
SMITHFIELD RI
02917-2611
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-606-1004
  • Fax: 401-606-1153
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01742
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: