Provider Demographics
NPI:1013903152
Name:DESILLIER, PAUL S (PAC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:DESILLIER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S HUNTINGTON AVE RM 42
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4817
Mailing Address - Country:US
Mailing Address - Phone:857-364-4720
Mailing Address - Fax:857-364-2033
Practice Address - Street 1:150 S HUNTINGTON AVE RM 42
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:857-364-4720
Practice Address - Fax:857-364-2033
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1784363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADEAP1532Medicare ID - Type Unspecified
P38979Medicare UPIN