Provider Demographics
NPI:1265257943
Name:ANTHONY, MICHAEL ALEXANDER
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:ANTHONY
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 1:113 WICKENDEN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4364
Mailing Address - Country:US
Mailing Address - Phone:401-453-0120
Mailing Address - Fax:
Practice Address - Street 1:113 WICKENDEN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4364
Practice Address - Country:US
Practice Address - Phone:401-453-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN04287363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care