Basic Information
| Provider Information | |||||||||
| NPI: | 1275836165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | XU | ||||||||
| FirstName: | DAWSON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | XU | ||||||||
| OtherFirstName: | DAOSONG | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9484 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029409484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018542500 | ||||||||
| FaxNumber: | 4018542519 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015191604 | ||||||||
| FaxNumber: | 4012720538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA00571 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 04112011 | 01 | RI | BCBSRI | OTHER | DX83438 | 05 | RI | MEDICAID | 0019876 | 01 | RI | RI MEDICARE | OTHER | 03102011 | 01 | RI | NHPRI | OTHER | 939025129 | 01 | RI | RI MEDICARE GROUP | OTHER |