Provider Demographics
NPI:1306892062
Name:PEACOCK, JAMES (CRNA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ORMS ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2228
Mailing Address - Country:US
Mailing Address - Phone:401-453-0666
Mailing Address - Fax:401-453-9619
Practice Address - Street 1:101 PAGE ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-3464
Practice Address - Country:US
Practice Address - Phone:508-973-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRNA36627367500000X
MA255585367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1286OtherBLUE CROSS PROVIDER NUMBER
RI001803OtherBLUE CHIP PROVIDER NUMBER
MA1306892062OtherFALLON
NA1226Medicare PIN
MANA1226Medicare PIN