Healthcare Provider Details

I. General information

NPI: 1043133457
Provider Name (Legal Business Name): JONATHAN DIMENT ECKEL JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 WELLS ST STE 201
WESTERLY RI
02891-2923
US

IV. Provider business mailing address

17 WELLS ST STE 201
WESTERLY RI
02891-2923
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-2033
  • Fax: 401-596-9294
Mailing address:
  • Phone: 401-596-2033
  • Fax: 401-596-9294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01959
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA01959
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01959
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: