Provider Demographics
NPI:1790766673
Name:KISNER, ALAN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:MICHAEL
Last Name:KISNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2816
Mailing Address - Country:US
Mailing Address - Phone:631-424-4004
Mailing Address - Fax:631-424-4027
Practice Address - Street 1:100 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2816
Practice Address - Country:US
Practice Address - Phone:631-424-4004
Practice Address - Fax:631-424-4027
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1216841174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB12856Medicare UPIN
NY318351Medicare PIN