Provider Demographics
NPI:1114016995
Name:DESANTIS, GINO (PA-C)
Entity Type:Individual
Prefix:
First Name:GINO
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:M
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 1:12 GILL ST
Mailing Address - Street 2:STE 3000
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1728
Mailing Address - Country:US
Mailing Address - Phone:781-937-4522
Mailing Address - Fax:
Practice Address - Street 1:2701 DEKALB PIKE
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-1820
Practice Address - Country:US
Practice Address - Phone:610-278-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant