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General NPI Number Information
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NPI Number | 1770191009
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Entity Type | Individual
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Provider Name | MAURA K GONCALO PAC
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Gender | Female
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Dates
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Enumeration Date | 07/22/2020
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Last Update Date | 03/03/2023
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Provider Practice Location Address
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Address Line | 395 ATWOOD AVE
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City | CRANSTON
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State | RI
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Zip | 02920-4358
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Country | US
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Telephone | 401-464-9751
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Fax | 401-464-9755
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Provider Business Mailing Address
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Address Line | 442 HIGHLAND RD
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City | TIVERTON
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State | RI
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Zip | 02878-4429
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Country | US
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Telephone | 401-297-6669
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 7639
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA01255
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License Number State | RI
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