Healthcare Provider Details

I. General information

NPI: 1356397178
Provider Name (Legal Business Name): LISA J. LAZARO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2559
US

IV. Provider business mailing address

PO BOX 409041
ATLANTA GA
30384-9041
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-7185
  • Fax:
Mailing address:
  • Phone: 800-377-8721
  • Fax: 304-523-2241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010883-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: