MEDICARE: MR. NICHOLAS JOSEPH CHARBONEAU 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
1	363A00000X	Physician Assistant	4011	CT

General Provider Information

NPI Number	:	1306353693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS JOSEPH CHARBONEAU PA-C

Provider Business Mailing Address
First Line	:	12 BUCKTHORN LN
Second Line	:
City	:	NORTH ATTLEBORO
State	:	MA
Zip	:	02760-4760
Country	:	US
Telephone Number	:	508-838-1442
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 BUCKTHORN LN
Second Line	:
City	:	NORTH ATTLEBORO
State	:	MA
Zip	:	02760-4760
Country	:	US
Telephone Number	:	508-838-1442
Fax Number	:

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

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	01/08/2018

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