Provider Demographics
NPI:1306353693
Name:CHARBONEAU, NICHOLAS JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:CHARBONEAU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BUCKTHORN LN
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-4760
Mailing Address - Country:US
Mailing Address - Phone:508-838-1442
Mailing Address - Fax:
Practice Address - Street 1:12 BUCKTHORN LN
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-4760
Practice Address - Country:US
Practice Address - Phone:508-838-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4011363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant