Provider Demographics
NPI:1629042858
Name:DESANTIS, MEGAN G (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:G
Last Name:DESANTIS
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 1:35 QUAIL CT
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03109-5930
Mailing Address - Country:US
Mailing Address - Phone:603-232-1976
Mailing Address - Fax:
Practice Address - Street 1:4 ELLIOT WAY
Practice Address - Street 2:SUITE302
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3547
Practice Address - Country:US
Practice Address - Phone:603-627-1887
Practice Address - Fax:603-627-1890
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0462363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30332481Medicaid
NH30332481Medicaid
NHAP1903Medicare ID - Type Unspecified