Healthcare Provider Details

I. General information

NPI: 1518049469
Provider Name (Legal Business Name): DOUGLAS BRUCE GENEREUX PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 KENYON AVE STE 280
WAKEFIELD RI
02879-4253
US

IV. Provider business mailing address

PO BOX 229
WAKEFIELD RI
02880-0229
US

V. Phone/Fax

Practice location:
  • Phone: 401-284-1212
  • Fax: 401-788-8730
Mailing address:
  • Phone: 401-788-3929
  • Fax: 401-788-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00199
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00199
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: