Provider Demographics
NPI:1861606220
Name:DESHANE, ROBERT SCOTT (PA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:SCOTT
Last Name:DESHANE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DARTMOUTH HITCHCOCK - NEURO-CRITICAL CARE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756
Mailing Address - Country:US
Mailing Address - Phone:603-650-5104
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DARTMOUTH HITCHCOCK - NEURO-CRITICAL CARE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756
Practice Address - Country:US
Practice Address - Phone:603-650-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004991363A00000X
NH1417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861606220Medicaid
MIMI3233539Medicare PIN