Provider Demographics
NPI:1962598516
Name:DELUCA, WALTER (PAC)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:DELUCA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-1405
Mailing Address - Country:US
Mailing Address - Phone:401-434-0022
Mailing Address - Fax:401-434-6111
Practice Address - Street 1:684 WARREN AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-1405
Practice Address - Country:US
Practice Address - Phone:401-434-0022
Practice Address - Fax:401-434-6111
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT289363AM0700X
RIPA00002363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7005920Medicaid
MT289OtherSTATE LIC NUMBER
MT000096303OtherBLUE CROSS NUMBER
RI979006386OtherMEDICARE PTAN
MT0438260Medicaid
MT289OtherSTATE LIC NUMBER
RI979006386OtherMEDICARE PTAN