Provider Demographics
NPI:1063408144
Name:DEDEUS, KIM H (PA-C)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:H
Last Name:DEDEUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 BORTHWICK AVE
Mailing Address - Street 2:MEDICAL OFFICE BUILDING SUITE 301
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7128
Mailing Address - Country:US
Mailing Address - Phone:603-431-5858
Mailing Address - Fax:603-431-5818
Practice Address - Street 1:333 BORTHWICK AVE
Practice Address - Street 2:MEDICAL OFFICE BUILDING SUITE 301
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7128
Practice Address - Country:US
Practice Address - Phone:603-431-5858
Practice Address - Fax:603-431-5818
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0504P363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHAP2153Medicare ID - Type Unspecified
NHQ19183Medicare UPIN