Provider Demographics
NPI:1790590693
Name:DESROSIERS, JEAN ALIX (PA)
Entity type:Individual
Prefix:
First Name:JEAN ALIX
Middle Name:
Last Name:DESROSIERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6704 RIO PINAR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-3840
Mailing Address - Country:US
Mailing Address - Phone:954-665-0142
Mailing Address - Fax:
Practice Address - Street 1:6704 RIO PINAR
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-3840
Practice Address - Country:US
Practice Address - Phone:954-665-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR002270-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical