Provider Demographics
NPI:1720556517
Name:DESALLE, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:DESALLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 LOCUST ST
Mailing Address - Street 2:SUITE 236
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15219-5114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 LOCUST ST
Practice Address - Street 2:SUITE 236
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15219-5114
Practice Address - Country:US
Practice Address - Phone:412-232-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant