Healthcare Provider Details

I. General information

NPI: 1811194558
Provider Name (Legal Business Name): RICHARD J. DESAUTEL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 COUNTY ROUTE 26A
STUYVESANT NY
12173-2410
US

IV. Provider business mailing address

88 COUNTY ROUTE 26A
STUYVESANT NY
12173-2410
US

V. Phone/Fax

Practice location:
  • Phone: 413-429-5139
  • Fax:
Mailing address:
  • Phone: 413-429-5139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number004966
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP081740
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP01488
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number049762-23
License Number StateNH
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number153541
License Number StateMA
# 6
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF340630
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: