Provider Demographics
NPI:1891981254
Name:DELISLE, BRENDA ANN (PA)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:ANN
Last Name:DELISLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGHLAND SHORES RD
Mailing Address - Street 2:
Mailing Address - City:CASCO
Mailing Address - State:ME
Mailing Address - Zip Code:04015
Mailing Address - Country:US
Mailing Address - Phone:207-221-3371
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL MEDICAL CENTER
Practice Address - Street 2:CMR 402
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:0637-186-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP67363A00000X
GU42363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant