Provider Demographics
NPI:1801469952
Name:FORTIN, DANIEL WILSON (RN)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WILSON
Last Name:FORTIN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BORDEN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-5672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN46711163WC0200X
MARN2322992367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine