Provider Demographics
NPI:1134162043
Name:BISHOP, KIRSTEN (PA)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:BISHOP
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 1:117 FOOTE AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6947
Mailing Address - Country:US
Mailing Address - Phone:716-338-9200
Mailing Address - Fax:716-338-9250
Practice Address - Street 1:117 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6947
Practice Address - Country:US
Practice Address - Phone:716-338-9200
Practice Address - Fax:716-338-9250
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007976363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2141633Medicaid
NYCC4858Medicare ID - Type Unspecified
NY2141633Medicaid