Healthcare Provider Details

I. General information

NPI: 1760717219
Provider Name (Legal Business Name): LAURA FAVICCHIO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA SHARP PA

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
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

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

V. Phone/Fax

Practice location:
  • Phone: 401-432-2500
  • Fax: 401-453-8220
Mailing address:
  • Phone: 401-432-2500
  • Fax: 401-453-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00737
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3844
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3844
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00737
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: