Provider Demographics
NPI:1699085043
Name:BOUSKILA, STEPHANE DANIEL (PA)
Entity type:Individual
Prefix:
First Name:STEPHANE
Middle Name:DANIEL
Last Name:BOUSKILA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 NEW DORP LANE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:718-351-1115
Mailing Address - Fax:646-365-3017
Practice Address - Street 1:515 MADISON AVENUE
Practice Address - Street 2:SUITE #1102
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:212-729-9200
Practice Address - Fax:646-365-3017
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23014325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant