Basic Information
| Provider Information | |||||||||
| NPI: | 1164483335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESHONG | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 OLD COURT RD | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | RANDALLSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211335103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106015524 | ||||||||
| FaxNumber: | 4106018946 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD COURT RD | ||||||||
| Address2: | |||||||||
| City: | RANDALLSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211335103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105212200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | C0002602 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.