=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215187794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICARDO PLATA PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2008
-----------------------------------------------------
Last Update Date | 02/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 COLCORD ST
-----------------------------------------------------
City | SOUTH BERWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 03908-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-384-4949
-----------------------------------------------------
Fax | 207-384-4273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 412503
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02241-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-384-4949
-----------------------------------------------------
Fax | 207-384-4273
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1652
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA2118
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------