Healthcare Provider Details

I. General information

NPI: 1013903152
Provider Name (Legal Business Name): PAUL S DESILLIER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE RM 42
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE RM 42
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-4720
  • Fax: 857-364-2033
Mailing address:
  • Phone: 857-364-4720
  • Fax: 857-364-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1784
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1784
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: