Provider Demographics
NPI:1750483889
Name:JONSSON, LAILA M (PA)
Entity Type:Individual
Prefix:
First Name:LAILA
Middle Name:M
Last Name:JONSSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 RIVER VUE AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-4717
Mailing Address - Country:US
Mailing Address - Phone:401-272-7799
Mailing Address - Fax:
Practice Address - Street 1:195 COLLYER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1869
Practice Address - Country:US
Practice Address - Phone:401-272-7799
Practice Address - Fax:401-272-9299
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI26576OtherBLUE SHIELD
RI7007330Medicaid
RI7007330Medicaid