Provider Demographics
NPI:1568488633
Name:DESIMONE, JEROLD ALLEN I (PA)
Entity Type:Individual
Prefix:MR
First Name:JEROLD
Middle Name:ALLEN
Last Name:DESIMONE
Suffix:I
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 E HENRIETTA RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1419
Mailing Address - Country:US
Mailing Address - Phone:585-292-6440
Mailing Address - Fax:585-292-6491
Practice Address - Street 1:945 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1419
Practice Address - Country:US
Practice Address - Phone:585-292-6440
Practice Address - Fax:585-292-6491
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4244363AM0700X
NY23-004244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP019004244OtherEXCELLUS
NYPA0100OtherPREFERRED CARE