Basic Information
| Provider Information | |||||||||
| NPI: | 1356789549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RISTUCCIA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | BERNICE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16149 | ||||||||
| Address2: | |||||||||
| City: | RUMFORD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029160697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539625 | ||||||||
| FaxNumber: | 4014357069 | ||||||||
| Practice Location | |||||||||
| Address1: | 227 CENTERVILLE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028864394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017363731 | ||||||||
| FaxNumber: | 4017328484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2013 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA00714 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.