Provider Demographics
NPI:1336202043
Name:BRENDESE, STEPHEN C (MPA-C)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:C
Last Name:BRENDESE
Suffix:
Gender:M
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:989 ROUTE 146
Practice Address - Street 2:BLDG 200
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3646
Practice Address - Country:US
Practice Address - Phone:518-383-0891
Practice Address - Fax:518-383-1662
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1071318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03455956Medicaid
NY03455956Medicaid
NYJ400072119Medicare PIN