Provider Demographics
NPI:1306879242
Name:ST. DENNIS, RICHARD A (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:ST. DENNIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:A
Other - Last Name:ST. DENNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 62939
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-1551
Mailing Address - Country:US
Mailing Address - Phone:859-291-4800
Mailing Address - Fax:833-694-1507
Practice Address - Street 1:10 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-6716
Practice Address - Country:US
Practice Address - Phone:401-826-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001203363A00000X
RIPA00503363A00000X, 363A00000X
CT0001203363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRS77579Medicaid
RI0013223Medicare PIN