Provider Demographics
NPI:1578588166
Name:BERMUDEZ, MARIA A (PHYSICIAN ASST PAC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:A
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASST PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 MINERAL SPRING AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-2808
Mailing Address - Country:US
Mailing Address - Phone:401-722-0569
Mailing Address - Fax:
Practice Address - Street 1:42 PARK PLACE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-729-0080
Practice Address - Fax:401-729-0438
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
404960OtherBCHIP
30677OtherBC
S78732Medicare UPIN
RI979005759Medicare PIN
30677OtherBC