Provider Demographics
NPI:1740988401
Name:FERNANDEZ THEN, BISMALIA IVON (SA-C)
Entity type:Individual
Prefix:
First Name:BISMALIA
Middle Name:IVON
Last Name:FERNANDEZ THEN
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 KOSSUTH AVE APT F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2444
Mailing Address - Country:US
Mailing Address - Phone:551-482-7078
Mailing Address - Fax:
Practice Address - Street 1:3405 KOSSUTH AVE APT F
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2444
Practice Address - Country:US
Practice Address - Phone:551-482-7078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-121246ZC0007X
PR001285-P.A.363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant