Basic Information
| Provider Information | |||||||||
| NPI: | 1396800520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNLEAVY | ||||||||
| FirstName: | MARYKATE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSPAS, PA-C | ||||||||
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| 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: | 12/27/2006 | ||||||||
| LastUpdateDate: | 02/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001873 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA00489 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 05/29/2009 | 01 | RI | BCBS | OTHER | MD74353 | 05 | RI | MEDICAID | 1396800520 | 01 | RI | NPI | OTHER | 939025129 | 01 | RI | RI MEDICARE GROUP NUMBER | OTHER | 05/14/2009 | 01 | RI | NHPRI | OTHER | 979006382 | 01 | RI | RI MEDICARE | OTHER |