Provider Demographics
NPI:1033443205
Name:BUSSOLETTI, KERRY ELAINE (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ELAINE
Last Name:BUSSOLETTI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ELAINE
Other - Last Name:SALINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 W CRESCENT PARK
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2111
Mailing Address - Country:US
Mailing Address - Phone:814-723-2510
Mailing Address - Fax:814-723-4654
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2111
Practice Address - Country:US
Practice Address - Phone:814-723-2510
Practice Address - Fax:814-723-4654
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant