Provider Demographics
NPI:1801906797
Name:BISESI, RUSSELL WILLIAM (APRN BC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WILLIAM
Last Name:BISESI
Suffix:
Gender:M
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:136 WELD ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1042
Mailing Address - Country:US
Mailing Address - Phone:617-755-9898
Mailing Address - Fax:
Practice Address - Street 1:420 MAIN ST
Practice Address - Street 2:BOSTON HEALTH CARE
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-3753
Practice Address - Country:US
Practice Address - Phone:508-660-7949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA242633364SP0807X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health