Provider Demographics
NPI:1932871910
Name:DEANOVIC, DESIREE (PA-C)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:DEANOVIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 86TH CT W
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-4234
Mailing Address - Country:US
Mailing Address - Phone:952-456-2042
Mailing Address - Fax:
Practice Address - Street 1:300 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6319
Practice Address - Country:US
Practice Address - Phone:507-333-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13767207R00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine