Healthcare Provider Details

I. General information

NPI: 1053495861
Provider Name (Legal Business Name): LISA RIBONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 WELLNESS WAY STE G06
LATHAM NY
12110-2135
US

IV. Provider business mailing address

6 WELLNESS WAY STE 201
LATHAM NY
12110-2156
US

V. Phone/Fax

Practice location:
  • Phone: 518-786-1600
  • Fax: 518-786-1606
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number201133
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number201133
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: