Basic Information
| Provider Information | |||||||||
| NPI: | 1063408144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEDEUS | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 BORTHWICK AVE | ||||||||
| Address2: | MEDICAL OFFICE BUILDING SUITE 301 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038017128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034315858 | ||||||||
| FaxNumber: | 6034315818 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 BORTHWICK AVE | ||||||||
| Address2: | MEDICAL OFFICE BUILDING SUITE 301 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038017128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034315858 | ||||||||
| FaxNumber: | 6034315818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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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 | 363AS0400X | 0504P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.