Provider Demographics
NPI:1801135553
Name:DESJARDINS, ANTHONY (MS, CCP)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:DESJARDINS
Suffix:
Gender:M
Credentials:MS, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 W CORRAL GATE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2585
Mailing Address - Country:US
Mailing Address - Phone:413-313-3030
Mailing Address - Fax:
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-773-2412
Practice Address - Fax:928-214-2757
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPL082242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist