Provider Demographics
NPI:1619022506
Name:DABISSIERE, MARINIQUE (PA)
Entity Type:Individual
Prefix:MS
First Name:MARINIQUE
Middle Name:
Last Name:DABISSIERE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1404
Mailing Address - Country:US
Mailing Address - Phone:516-771-0930
Mailing Address - Fax:
Practice Address - Street 1:130 E 77TH ST
Practice Address - Street 2:9 BLACK HALL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1851
Practice Address - Country:US
Practice Address - Phone:212-434-2606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant