Provider Demographics
NPI:1043736739
Name:DESMARAIS, ALYSSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:DESMARAIS
Suffix:
Gender:F
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 WILDFLOWER CIR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-4590
Mailing Address - Country:US
Mailing Address - Phone:413-454-1182
Mailing Address - Fax:
Practice Address - Street 1:3455 MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1147
Practice Address - Country:US
Practice Address - Phone:413-733-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1142951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant