Provider Demographics
NPI:1730926940
Name:RICHARD, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:RICHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WHETSTONE ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01985-1432
Mailing Address - Country:US
Mailing Address - Phone:978-914-4086
Mailing Address - Fax:
Practice Address - Street 1:33 STANIFORD ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3105
Practice Address - Country:US
Practice Address - Phone:401-421-8800
Practice Address - Fax:401-421-2492
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant