Provider Demographics
NPI:1083800742
Name:BRISENO, ANTONE (PA)
Entity Type:Individual
Prefix:
First Name:ANTONE
Middle Name:
Last Name:BRISENO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:75-5751 KUAKINI HWY
Mailing Address - Street 2:STE 203
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1753
Mailing Address - Country:US
Mailing Address - Phone:808-326-3891
Mailing Address - Fax:808-329-9370
Practice Address - Street 1:116 WEST MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:MCCLOUD
Practice Address - State:CA
Practice Address - Zip Code:96057-1143
Practice Address - Country:US
Practice Address - Phone:530-964-2389
Practice Address - Fax:530-964-3141
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA17420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant