Provider Demographics
NPI:1679188494
Name:DESTA ANTHONY MOBILE NP ADULT HEALTH, PLLC
Entity Type:Organization
Organization Name:DESTA ANTHONY MOBILE NP ADULT HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DESAT
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-559-1965
Mailing Address - Street 1:8241 PENSTOCK WAY
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9401
Mailing Address - Country:US
Mailing Address - Phone:315-413-3848
Mailing Address - Fax:315-692-4292
Practice Address - Street 1:8241 PENSTOCK WAY
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-9401
Practice Address - Country:US
Practice Address - Phone:315-413-3848
Practice Address - Fax:315-692-4292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty