Provider Demographics
NPI:1780898932
Name:MODRACEK, DARRYK JAMES (PA-C)
Entity type:Individual
Prefix:MR
First Name:DARRYK
Middle Name:JAMES
Last Name:MODRACEK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:38 DR BRALEY RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02770-1900
Mailing Address - Country:US
Mailing Address - Phone:508-858-8910
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:RHODE ISLAND HOSPITAL. DEPT OF CARDIAC SURGERY (CTIC)
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant