Basic Information
| Provider Information | |||||||||
| NPI: | 1811313620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESAMOURS | ||||||||
| FirstName: | PATRICK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6934 AVIATION BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210612593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439490814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6934 AVIATION BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210612593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439490814 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2014 | ||||||||
| LastUpdateDate: | 05/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0005311 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.