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NPI Code Detail

MEDICARE: MR. ETHAN KLAUSMEYER PA-C

MEDICARE: MR. ETHAN KLAUSMEYER PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantC0009110MD
2363A00000XPhysician AssistantPA01425RI

General Provider Information

NPI Number : 1174162481
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ETHAN KLAUSMEYER PA-C
Provider Business Mailing Address
First Line : 117 ELLENFIELD ST STE 101
Second Line :
City : PROVIDENCE
State : RI
Zip : 02905-4541
Country : US
Telephone Number : 401-444-6779
Fax Number :
Provider Business Practice Location Address
First Line : 17 AIRPORT RD
Second Line :
City : WARWICK
State : RI
Zip : 02889-1001
Country : US
Telephone Number : 401-606-3110
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/03/2020
Last Update Date : 08/06/2025

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