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General NPI Number Information
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NPI Number | 1144722372
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Entity Type | Individual
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Provider Name | NICOLAS JUNIOR DESJARDINS PA-C
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Gender | Male
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Dates
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Enumeration Date | 03/03/2018
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 96 SUMMER ST APT 1
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City | SOMERVILLE
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State | MA
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Zip | 02143-2707
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Country | US
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Telephone | 617-834-8784
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Fax |
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Provider Business Mailing Address
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Address Line | 96 SUMMER ST APT 1
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City | SOMERVILLE
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State | MA
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Zip | 02143-2707
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Country | US
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Telephone | 617-834-8784
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA6469
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number | PA6469
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | PA6469
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License Number State | MA
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA6469
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License Number State | MA
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Taxonomy #5
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number | PA6469
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License Number State | MA
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