Provider Demographics
NPI:1194971614
Name:AMISANO, MARK DAVID (RN)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:AMISANO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:D
Other - Last Name:AMISANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:220 DEERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-3147
Mailing Address - Country:US
Mailing Address - Phone:315-303-5145
Mailing Address - Fax:
Practice Address - Street 1:526 OLD LIVERPOOL RD
Practice Address - Street 2:BUILDING 1, SUITE 1
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6238
Practice Address - Country:US
Practice Address - Phone:315-453-5537
Practice Address - Fax:315-453-7138
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553471-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse