Provider Demographics
NPI:1063641009
Name:DESORMES, MARY SHIRLEY (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SHIRLEY
Last Name:DESORMES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7207 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-7618
Mailing Address - Country:US
Mailing Address - Phone:917-576-8778
Mailing Address - Fax:
Practice Address - Street 1:82-68 164 STREET
Practice Address - Street 2:QUEENS HOSPITAL CENTER
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-658-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY008617-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant