Healthcare Provider Details

I. General information

NPI: 1407327794
Provider Name (Legal Business Name): JESSICA DEZEGO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 POTTER BLVD
BRIGHTWATERS NY
11718-1830
US

IV. Provider business mailing address

404 POTTER BLVD
BRIGHTWATERS NY
11718-1830
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-0055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022967
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: