Provider Demographics
NPI:1265080832
Name:STERN, MICHAEL ELLIS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ELLIS
Last Name:STERN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7260 POST RD
Mailing Address - Street 2:STE 103
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-3246
Mailing Address - Country:US
Mailing Address - Phone:401-744-6447
Mailing Address - Fax:
Practice Address - Street 1:46 BARNES ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-1502
Practice Address - Country:US
Practice Address - Phone:401-744-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN02134363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care