Provider Demographics
NPI:1376626440
Name:FURCOLO, KENNETH A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:FURCOLO
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 1:285 PROMENADE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-5719
Mailing Address - Country:US
Mailing Address - Phone:401-777-7000
Mailing Address - Fax:401-459-4006
Practice Address - Street 1:285 PROMENADE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-5719
Practice Address - Country:US
Practice Address - Phone:401-459-4001
Practice Address - Fax:401-459-4006
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00067363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI20622OtherBLUE CROSS
RI406284OtherBLUE CHIP
RI406284OtherBLUE CHIP