Provider Demographics
NPI:1841337987
Name:AMEDEE, LISETTE (PA)
Entity type:Individual
Prefix:MRS
First Name:LISETTE
Middle Name:
Last Name:AMEDEE
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 1:345 SCHERMERHORN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1025
Mailing Address - Country:US
Mailing Address - Phone:718-403-3547
Mailing Address - Fax:718-858-0145
Practice Address - Street 1:345 SCHERMERHORN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1025
Practice Address - Country:US
Practice Address - Phone:718-403-3547
Practice Address - Fax:718-858-0145
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04118OtherLICENSE