Provider Demographics
NPI:1629363585
Name:BISSON, STEPHANIE KENNEDY (PA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:KENNEDY
Last Name:BISSON
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 1:22 TRYON ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3246
Mailing Address - Country:US
Mailing Address - Phone:518-478-4884
Mailing Address - Fax:
Practice Address - Street 1:2215 BURDETT AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2466
Practice Address - Country:US
Practice Address - Phone:518-271-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP80184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant