Provider Demographics
NPI:1588859961
Name:MISLE, JAIME DEAN (PA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:DEAN
Last Name:MISLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 4TH AVE APT 3R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-1016
Mailing Address - Country:US
Mailing Address - Phone:718-490-2385
Mailing Address - Fax:
Practice Address - Street 1:660 4TH AVE APT 3R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-1016
Practice Address - Country:US
Practice Address - Phone:718-490-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant