Healthcare Provider Details

I. General information

NPI: 1063408144
Provider Name (Legal Business Name): KIM H DEDEUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 BORTHWICK AVE MEDICAL OFFICE BUILDING SUITE 301
PORTSMOUTH NH
03801-7128
US

IV. Provider business mailing address

333 BORTHWICK AVE MEDICAL OFFICE BUILDING SUITE 301
PORTSMOUTH NH
03801-7128
US

V. Phone/Fax

Practice location:
  • Phone: 603-431-5858
  • Fax: 603-431-5818
Mailing address:
  • Phone: 603-431-5858
  • Fax: 603-431-5818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0504P
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: