Provider Demographics
NPI:1659346104
Name:LAFONTAINE, AMY G (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:G
Last Name:LAFONTAINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:G
Other - Last Name:BURLINGAME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:45 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:CHEPACHET
Mailing Address - State:RI
Mailing Address - Zip Code:02814-1444
Mailing Address - Country:US
Mailing Address - Phone:401-808-0165
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI29687-6OtherBLUECROSS BLUESHIELD
RI9004038Medicaid
RI412788OtherBLUE CHIP
RIP00309459OtherRAILROAD
RI412788OtherBLUE CHIP
RI29687-6OtherBLUECROSS BLUESHIELD