Healthcare Provider Details

I. General information

NPI: 1871715433
Provider Name (Legal Business Name): MICHAEL DESORCIE CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST STREET SW
ROCHESTER MN
55905
US

IV. Provider business mailing address

407 17TH STREET SE
ROCHESTER MN
55904
US

V. Phone/Fax

Practice location:
  • Phone: 507-255-5977
  • Fax:
Mailing address:
  • Phone: 507-529-1849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: