Basic Information
| Provider Information | |||||||||
| NPI: | 1043685308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROHANNESIAN | ||||||||
| FirstName: | ASENA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | LEVENT | ||||||||
| OtherFirstName: | ASENA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 46 ALBION ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066052602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033306000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 425 THORME ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066063418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032754115 | ||||||||
| FaxNumber: | 2032750198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2015 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 6410 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.