Healthcare Provider Details

I. General information

NPI: 1689770901
Provider Name (Legal Business Name): LISA KOTYRA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0002
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 679B
ROCHESTER NY
14642-0002
US

V. Phone/Fax

Practice location:
  • Phone: 585-273-3760
  • Fax: 585-273-1129
Mailing address:
  • Phone: 585-273-3760
  • Fax: 585-273-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF301044
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number424459
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: