Healthcare Provider Details

I. General information

NPI: 1063969061
Provider Name (Legal Business Name): NICHOLAS ANGELO LASARSO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COUNTRY CLUB RD
QUEENSBURY NY
12804-1702
US

IV. Provider business mailing address

2 COUNTRY CLUB RD
QUEENSBURY NY
12804-1702
US

V. Phone/Fax

Practice location:
  • Phone: 518-926-2075
  • Fax: 518-926-2020
Mailing address:
  • Phone: 518-926-2075
  • Fax: 518-926-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4697
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT4697
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT4697
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number047240-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: