Provider Demographics
NPI:1477834612
Name:BRYCE, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:BRYCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISSETTE
Other - Middle Name:
Other - Last Name:BRYCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1585 BROADWAY FL 8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-8200
Mailing Address - Country:US
Mailing Address - Phone:212-761-6300
Mailing Address - Fax:
Practice Address - Street 1:1585 BROADWAY FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8200
Practice Address - Country:US
Practice Address - Phone:212-761-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008673363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical