Provider Demographics
NPI:1811194558
Name:DESAUTEL, RICHARD J (NP)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:J
Last Name:DESAUTEL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 COUNTY ROUTE 26A
Mailing Address - Street 2:
Mailing Address - City:STUYVESANT
Mailing Address - State:NY
Mailing Address - Zip Code:12173-2410
Mailing Address - Country:US
Mailing Address - Phone:413-429-5139
Mailing Address - Fax:
Practice Address - Street 1:88 COUNTY ROUTE 26A
Practice Address - Street 2:
Practice Address - City:STUYVESANT
Practice Address - State:NY
Practice Address - Zip Code:12173-2410
Practice Address - Country:US
Practice Address - Phone:413-429-5139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004966363LG0600X
MEAP081740363LG0600X
NMCNP01488363LG0600X
NH049762-23363LG0600X
MA153541363LG0600X
NYF340630363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431894499OtherMEDICAID - MAINECARE
NY03213898Medicaid
NY200213435OtherCDPHP
NY3012611OtherMVP
NY3012611OtherMVP
DE-NP5069Medicare PIN