Provider Demographics
NPI:1396800520
Name:DUNLEAVY, MARYKATE (MSPAS, PA-C)
Entity type:Individual
Prefix:
First Name:MARYKATE
Middle Name:
Last Name:DUNLEAVY
Suffix:
Gender:F
Credentials:MSPAS, 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:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001873363AM0700X
RIPA00489363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI05/29/2009OtherBCBS
RIMD74353Medicaid
RI1396800520OtherNPI
RI939025129OtherRI MEDICARE GROUP NUMBER
RI05/14/2009OtherNHPRI
RI979006382OtherRI MEDICARE