Provider Demographics
NPI:1619922358
Name:DESHONG, CARRIE DAWN (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DAWN
Last Name:DESHONG
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 1:109 RAYLOC DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21750-1518
Mailing Address - Country:US
Mailing Address - Phone:301-678-5187
Mailing Address - Fax:301-678-5797
Practice Address - Street 1:525 FULTON DRIVE
Practice Address - Street 2:
Practice Address - City:MCCONNELLSBURG
Practice Address - State:PA
Practice Address - Zip Code:17233
Practice Address - Country:US
Practice Address - Phone:717-485-3850
Practice Address - Fax:717-485-3725
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051061363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA051061OtherMEDICAL PHY ASST LICENSE
PAMA051061OtherMEDICAL PHY ASST LICENSE