Provider Demographics
NPI:1487473955
Name:BOCCANFUSO, MATTHEW (PTA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:BOCCANFUSO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 EAST AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:OAKLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:979 EAST AVE
Practice Address - Street 2:UNIT A
Practice Address - City:OAKLAND
Practice Address - State:RI
Practice Address - Zip Code:02858
Practice Address - Country:US
Practice Address - Phone:401-371-2890
Practice Address - Fax:401-371-2892
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA01042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist