MEDICARE: DONALD E. R. POISSON NPP

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
1	363LA2200X	Adult Health Nurse Practitioner	NPP21594	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	213417	OTHER	RI	BLUE CROSS PROVIDER ID

General Provider Information

NPI Number	:	1174519508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD E. R. POISSON NPP

Provider Business Mailing Address
First Line	:	1180 N INDIAN CANYON DR
Second Line	:	SUITE 408
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-4800
Country	:	US
Telephone Number	:	760-969-5200
Fax Number	:	760-969-5201

Provider Business Practice Location Address
First Line	:	1180 N INDIAN CANYON DR
Second Line	:	SUITE 408
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-4800
Country	:	US
Telephone Number	:	760-969-5200
Fax Number	:	760-969-5201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/08/2007

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