Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 261158 | NY |
NPI | 1154627370 |
---|---|
Provider Name | Dr. Micah Lissy |
First Address | Johnson City, NY 13790-2580 |
Second Address | Binghamton, NY 13903-1642 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2011 |
Last Update Date | 23/04/2013 |