Provider Demographics
NPI:1730527474
Name:DESCHRIJVER, ANTOIN JOHNSEN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:ANTOIN
Middle Name:JOHNSEN
Last Name:DESCHRIJVER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:ASSOCIATES SOUTH SHORE DERMATOLOGY SUITE 2H
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:SUITE 2H
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-773-7431
Practice Address - Fax:617-773-7995
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program