Provider Demographics
NPI:1699740720
Name:DUFRESNE, JOHN R (NP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:DUFRESNE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RESERVOIR AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6068
Mailing Address - Country:US
Mailing Address - Phone:401-946-2400
Mailing Address - Fax:401-946-0107
Practice Address - Street 1:1150 RESERVOIR AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6068
Practice Address - Country:US
Practice Address - Phone:401-946-2400
Practice Address - Fax:401-946-0107
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37176363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI24007-5OtherBLUECROSS BLUESHIELD
RI409038OtherBLUE CHIP
RI7057318Medicaid
P00217750OtherRAILROAD
P00217750OtherRAILROAD
RI24007-5OtherBLUECROSS BLUESHIELD