Basic Information
| Provider Information | |||||||||
| NPI: | 1891785689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESERRE | ||||||||
| FirstName: | STEVE | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 JORDAN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121808343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182740476 | ||||||||
| FaxNumber: | 5182740497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 000767 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 02555948 | 05 | NY | MEDICAID |