Provider Demographics
NPI:1063984417
Name:ANSONG, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:ANSONG
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 1:61 MCCLELLAN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-5619
Mailing Address - Country:US
Mailing Address - Phone:401-474-0392
Mailing Address - Fax:401-719-0651
Practice Address - Street 1:61 MCCLELLAN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-5619
Practice Address - Country:US
Practice Address - Phone:401-474-0392
Practice Address - Fax:401-719-0651
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)