Provider Demographics
NPI:1497455695
Name:BISSO, CHARLY ANNE
Entity type:Individual
Prefix:
First Name:CHARLY
Middle Name:ANNE
Last Name:BISSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 TABOR ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-7912
Mailing Address - Country:US
Mailing Address - Phone:917-572-0227
Mailing Address - Fax:
Practice Address - Street 1:90 MILLBURN AVE STE 206
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1933
Practice Address - Country:US
Practice Address - Phone:973-763-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00770400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant