Provider Demographics
NPI:1518049469
Name:GENEREUX, DOUGLAS BRUCE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:BRUCE
Last Name:GENEREUX
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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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
Practice Address - Street 2:C70
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-3922
Practice Address - Fax:401-793-7866
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2012-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
RI199363A00000X
RIPA00199363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant