Healthcare Provider Details

I. General information

NPI: 1306390869
Provider Name (Legal Business Name): ERIC BOETTJER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1785
US

IV. Provider business mailing address

455 TOLL GATE RD PRC AND CREDENTIALING
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-2520
  • Fax: 401-921-9212
Mailing address:
  • Phone: 401-273-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7762
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00889
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: