Provider Demographics
NPI:1982960696
Name:CERULLO, JAMES M (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:CERULLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WHIPPLE STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3258
Mailing Address - Country:US
Mailing Address - Phone:401-854-2504
Mailing Address - Fax:401-427-7795
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4793363A00000X
RIPA00645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant