Healthcare Provider Details

I. General information

NPI: 1003188814
Provider Name (Legal Business Name): JODI LASKY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 WESTPORT DR
WATERBURY CT
06706-2854
US

IV. Provider business mailing address

26 WESTPORT DR
WATERBURY CT
06706-2854
US

V. Phone/Fax

Practice location:
  • Phone: 203-565-4728
  • Fax:
Mailing address:
  • Phone: 203-565-4728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001139
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001139
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: