Provider Demographics
NPI:1003380106
Name:MCKIERNAN, CHELSEA M (PA-C)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:M
Last Name:MCKIERNAN
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 1:1 COMMERCE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1186
Mailing Address - Country:US
Mailing Address - Phone:401-793-8500
Mailing Address - Fax:401-793-8511
Practice Address - Street 1:1 COMMERCE ST STE 200
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1186
Practice Address - Country:US
Practice Address - Phone:401-793-8500
Practice Address - Fax:401-793-8511
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant