Provider Demographics
NPI:1952441776
Name:MIGNACCA, STEVEN A (PT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:A
Last Name:MIGNACCA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20555
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-0946
Mailing Address - Country:US
Mailing Address - Phone:401-228-7678
Mailing Address - Fax:401-228-7681
Practice Address - Street 1:697 WILLETT AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2642
Practice Address - Country:US
Practice Address - Phone:401-228-7678
Practice Address - Fax:401-228-7681
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPT01117OtherSTATE LICENSE NUMBER
RI0015873OtherMEDICARE PTAN