MEDICARE: BRANDY ANN BISTANY

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	225700000X	Massage Therapist	018332	NY

General Provider Information

NPI Number	:	1700549276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY ANN BISTANY

Provider Business Mailing Address
First Line	:	30 OAKLAND AVE
Second Line	:
City	:	PORT JEFFERSON
State	:	NY
Zip	:	11777-2171
Country	:	US
Telephone Number	:	516-639-4968
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 OAKLAND AVE
Second Line	:
City	:	PORT JEFFERSON
State	:	NY
Zip	:	11777-2171
Country	:	US
Telephone Number	:	516-639-4968
Fax Number	:

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

Provider Enumeration Date	:	10/20/2021
Last Update Date	:	10/20/2021

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