Healthcare Provider Details

I. General information

NPI: 1336101435
Provider Name (Legal Business Name): ROBERT MICHAEL DESIMONE LAT, ATC, EMT, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 WEATHERVANE RD
BILLERICA MA
01821-5658
US

IV. Provider business mailing address

8 WEATHERVANE RD
BILLERICA MA
01821-5658
US

V. Phone/Fax

Practice location:
  • Phone: 781-696-3538
  • Fax:
Mailing address:
  • Phone: 781-696-3538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number842787
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1501
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number269340
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: