Provider Demographics
NPI:1629448279
Name:BOHAN, LISLE
Entity Type:Individual
Prefix:
First Name:LISLE
Middle Name:
Last Name:BOHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 247TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11363-1639
Mailing Address - Country:US
Mailing Address - Phone:917-450-3266
Mailing Address - Fax:
Practice Address - Street 1:4102 247TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11363-1639
Practice Address - Country:US
Practice Address - Phone:917-450-3266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist