Provider Demographics
NPI:1912658493
Name:SAINRISTIL, JEAN WILKENS
Entity Type:Individual
Prefix:
First Name:JEAN WILKENS
Middle Name:
Last Name:SAINRISTIL
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 1:63 CHATHAM WEST DR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1310
Mailing Address - Country:US
Mailing Address - Phone:617-388-7243
Mailing Address - Fax:
Practice Address - Street 1:63 CHATHAM WEST DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1310
Practice Address - Country:US
Practice Address - Phone:617-388-7243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1160-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical