Provider Demographics
NPI:1629593355
Name:GAUTHIER, MARK JAMES (APRRN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:APRRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 LAMBERT LIND HWY
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1131
Mailing Address - Country:US
Mailing Address - Phone:401-681-4264
Mailing Address - Fax:401-681-4285
Practice Address - Street 1:75 LAMBERT LIND HWY
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1131
Practice Address - Country:US
Practice Address - Phone:401-681-4274
Practice Address - Fax:401-681-4285
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01648363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty