Provider Demographics
NPI:1144722372
Name:DESJARDINS, NICOLAS JUNIOR (PA-C)
Entity type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:JUNIOR
Last Name:DESJARDINS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 SUMMER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2707
Mailing Address - Country:US
Mailing Address - Phone:617-834-8784
Mailing Address - Fax:
Practice Address - Street 1:96 SUMMER ST APT 1
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-2707
Practice Address - Country:US
Practice Address - Phone:617-834-8784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-03
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6469363AS0400X, 174H00000X, 207X00000X, 363A00000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No174H00000XOther Service ProvidersHealth Educator
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No405300000XOther Service ProvidersPrevention Professional