Provider Demographics
NPI:1285407668
Name:FISKE, ALBERT S JR (PMHNP)
Entity type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:S
Last Name:FISKE
Suffix:JR
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 LOCUST AVE N
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1604
Mailing Address - Country:US
Mailing Address - Phone:631-310-7285
Mailing Address - Fax:
Practice Address - Street 1:90 E MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3176
Practice Address - Country:US
Practice Address - Phone:888-722-2072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF406359-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health