Provider Demographics
NPI:1043685308
Name:DEROHANNESIAN, ASENA
Entity type:Individual
Prefix:
First Name:ASENA
Middle Name:
Last Name:DEROHANNESIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASENA
Other - Middle Name:
Other - Last Name:LEVENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:46 ALBION ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-2602
Mailing Address - Country:US
Mailing Address - Phone:203-330-6000
Mailing Address - Fax:
Practice Address - Street 1:425 THORME ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3418
Practice Address - Country:US
Practice Address - Phone:203-275-4115
Practice Address - Fax:203-275-0198
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6410363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics