Provider Demographics
NPI:1700846904
Name:DEISENROTH, JOSHUA E (PA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:E
Last Name:DEISENROTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1200
Mailing Address - Country:US
Mailing Address - Phone:508-363-7180
Mailing Address - Fax:508-363-7164
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1200
Practice Address - Country:US
Practice Address - Phone:508-363-7180
Practice Address - Fax:508-363-7164
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP54105Medicare UPIN
MAAP1675Medicare ID - Type UnspecifiedMEDICARE NUMBER