Provider Demographics
NPI:1124557376
Name:RUNQUIST, JESSICA LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:RUNQUIST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:FALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1675 GAR HWY
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-3901
Mailing Address - Country:US
Mailing Address - Phone:508-490-5959
Mailing Address - Fax:508-490-5960
Practice Address - Street 1:1675 GAR HWY
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-3901
Practice Address - Country:US
Practice Address - Phone:508-490-5959
Practice Address - Fax:508-490-5960
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6233363A00000X
RIPA01115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant