Provider Demographics
NPI:1972570182
Name:BRISSETTE, PAMELA M (PA-C)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:BRISSETTE
Suffix:
Gender:F
Credentials: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 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:164 SUMMIT AVE # C70
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-4545
Practice Address - Fax:401-793-7866
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI27118-1OtherBLUE CROSS
RI411429OtherBLUECHIP
RIQ17809Medicare UPIN
RI9790035221Medicare PIN
RIS86798Medicare UPIN