Provider Demographics
NPI:1689826299
Name:DESHANEY, KATRINA J (PA-C)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:J
Last Name:DESHANEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:NH
Mailing Address - Zip Code:03741
Mailing Address - Country:US
Mailing Address - Phone:603-523-4343
Mailing Address - Fax:
Practice Address - Street 1:18 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:NH
Practice Address - Zip Code:03741
Practice Address - Country:US
Practice Address - Phone:603-523-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433129199Medicaid
MEMM9086OtherMEDICARE GROUP NUMBER