MEDICARE: JOSE SISON III LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	302975	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45-2465167	OTHER	NY	HOMECARE

General Provider Information

NPI Number	:	1710478029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE SISON III LPN

Provider Business Mailing Address
First Line	:	3 LEXINGTON HILLS UNIT 2
Second Line	:
City	:	HARRIMAN
State	:	NY
Zip	:	10926-3455
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 LEXINGTON HILLS UNIT 2
Second Line	:
City	:	HARRIMAN
State	:	NY
Zip	:	10926-3455
Country	:	US
Telephone Number	:	845-642-2337
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2018
Last Update Date	:	05/22/2018

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