Basic Information
Provider Information
NPI: 1003804972
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DESAMERO
FirstName: JONATHAN
MiddleName: LABAYO
NamePrefix: MR.
NameSuffix:  
Credential: FNP-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6232 ARDEN FOREST CIRCLE
Address2:  
City: CLEMMONS
State: NC
PostalCode: 270129402
CountryCode: US
TelephoneNumber: 3367782858
FaxNumber:  
Practice Location
Address1: 4530 PARK RD
Address2: SUITE 200
City: CHARLOTTE
State: NC
PostalCode: 282093716
CountryCode: US
TelephoneNumber: 7045276322
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/13/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X119624NCY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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