Provider Demographics
NPI:1124294947
Name:BISONG, ALOYSIUS T JR (PA)
Entity type:Individual
Prefix:MR
First Name:ALOYSIUS
Middle Name:T
Last Name:BISONG
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:P O BOZ 850001 DEPT # 8015
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32885-8015
Mailing Address - Country:US
Mailing Address - Phone:352-861-0440
Mailing Address - Fax:352-861-1869
Practice Address - Street 1:808 HIGHWAY 466
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-751-0040
Practice Address - Fax:352-751-2825
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105417363A00000X
FLPA9105417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9105417OtherMEDICAL LICENSE