Healthcare Provider Details

I. General information

NPI: 1306555750
Provider Name (Legal Business Name): JONATHAN BISSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S STATE ST
SHELBY MI
49455-1243
US

IV. Provider business mailing address

10767 E TRAVERSE HWY
TRAVERSE CITY MI
49684-6219
US

V. Phone/Fax

Practice location:
  • Phone: 231-861-2130
  • Fax:
Mailing address:
  • Phone: 231-861-2130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601011250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: