Basic Information
| Provider Information | |||||||||
| NPI: | 1851862759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESSUREAULT | ||||||||
| FirstName: | DENIS | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | C/O ST MARY'S HEALTH SYSTEM - PROVIDER ENROLLMENT | ||||||||
| Address2: | PO BOX 7291 | ||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042437291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778695 | ||||||||
| FaxNumber: | 2077778800 | ||||||||
| Practice Location | |||||||||
| Address1: | 172 KINSLEY ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038823000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1565 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.