Provider Demographics
NPI:1164738662
Name:DEARDORFF, SHERISE LE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHERISE
Middle Name:LE
Last Name:DEARDORFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHERISE
Other - Middle Name:LE
Other - Last Name:DENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1655 N CASS ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-9416
Practice Address - Country:US
Practice Address - Phone:260-563-2126
Practice Address - Fax:260-569-2494
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001777A363AM0700X
IL085003822363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL347710-014Medicare PIN