Provider Demographics
NPI:1871745133
Name:ALBANESE, ALISA MARIE
Entity type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:MARIE
Last Name:ALBANESE
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 1:5348 STRAWFLOWER DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1220
Mailing Address - Country:US
Mailing Address - Phone:315-458-1692
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP67542363AM0700X
NY013067363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03328383Medicaid
NYJ400043402Medicare PIN
NYJ400003603Medicare PIN