Provider Demographics
NPI:1669078440
Name:DEOSSA, JOHANNA (MD)
Entity type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:
Last Name:DEOSSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:DEOSSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1887
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10163-1887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 E 36TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3402
Practice Address - Country:US
Practice Address - Phone:212-686-6329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000067-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant