Healthcare Provider Details

I. General information

NPI: 1982261145
Provider Name (Legal Business Name): MAGNIM KISSAO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-6000
  • Fax:
Mailing address:
  • Phone: 718-283-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number023041
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: