Basic Information
| Provider Information | |||||||||
| NPI: | 1942975123 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLETTA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029072423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013005757 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2021 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01385 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.