Provider Demographics
NPI:1154739241
Name:RIBOURG, SONNLY (PA)
Entity type:Individual
Prefix:
First Name:SONNLY
Middle Name:
Last Name:RIBOURG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 HANCOCK ST
Mailing Address - Street 2:APT 1
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-1333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 CANAL ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-6701
Practice Address - Country:US
Practice Address - Phone:781-338-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-01
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant