Provider Demographics
NPI:1306390869
Name:BOETTJER, ERIC (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BOETTJER
Suffix:
Gender:M
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 1:455 TOLL GATE RD
Mailing Address - Street 2:PRC AND CREDENTIALING
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:
Practice Address - Street 1:125 METRO CENTER BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1785
Practice Address - Country:US
Practice Address - Phone:401-432-2520
Practice Address - Fax:401-921-9212
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7762363A00000X
RIPA00889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant