Healthcare Provider Details

I. General information

NPI: 1346770179
Provider Name (Legal Business Name): LISHAM ASHRAFIOUN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/07/2023
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CRITTENDEN BLVD
ROCHESTER NY
14642-1159
US

IV. Provider business mailing address

300 CRITTENDEN BLVD BOX PSYCH
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-273-5701
  • Fax:
Mailing address:
  • Phone: 585-273-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number22172
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number022172
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: