Healthcare Provider Details

I. General information

NPI: 1588377980
Provider Name (Legal Business Name): NICHOLAS WALTER MARTIROSSIAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WELLS ST
WESTERLY RI
02891-2922
US

IV. Provider business mailing address

222 POST RD STE 5B
WESTERLY RI
02891-2686
US

V. Phone/Fax

Practice location:
  • Phone: 401-348-3325
  • Fax:
Mailing address:
  • Phone: 401-523-3883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01535
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01535
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: