Healthcare Provider Details

I. General information

NPI: 1528756459
Provider Name (Legal Business Name): ABIGAIL ROSE DEZERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABBY R LOCKMAN

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3202
US

IV. Provider business mailing address

PO BOX 1730
RANCHO MIRAGE CA
92270-1058
US

V. Phone/Fax

Practice location:
  • Phone: 760-568-2684
  • Fax:
Mailing address:
  • Phone: 760-766-1246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number63267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: