Provider Demographics
NPI:1659321776
Name:DESROSIERS, HOLLY LEIGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:LEIGH
Last Name:DESROSIERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:LEIGH
Other - Last Name:BERTHELETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:184 TARRYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-2713
Mailing Address - Country:US
Mailing Address - Phone:603-627-1102
Mailing Address - Fax:603-647-5524
Practice Address - Street 1:184 TARRYTOWN RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-2713
Practice Address - Country:US
Practice Address - Phone:603-627-1102
Practice Address - Fax:603-647-5524
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0583P363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30334287Medicaid
Q69557Medicare UPIN
NH30334287Medicaid