Provider Demographics
NPI:1275072233
Name:DESTITO, ERIN
Entity Type:Individual
Prefix:MISS
First Name:ERIN
Middle Name:
Last Name:DESTITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:HOOSICK FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12090-2211
Mailing Address - Country:US
Mailing Address - Phone:518-810-6277
Mailing Address - Fax:
Practice Address - Street 1:121 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:HOOSICK FALLS
Practice Address - State:NY
Practice Address - Zip Code:12090-2211
Practice Address - Country:US
Practice Address - Phone:518-810-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY020813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program