Provider Demographics
NPI:1215281092
Name:DESUCRE, GRACE JACQUELINE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:JACQUELINE
Last Name:DESUCRE
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 1:302 ESSEX CT
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-6533
Mailing Address - Country:US
Mailing Address - Phone:203-550-2037
Mailing Address - Fax:
Practice Address - Street 1:161 FORT WASHINGTON AVE FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-932-5169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016203363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical