Healthcare Provider Details

I. General information

NPI: 1023342003
Provider Name (Legal Business Name): LAURA POLITO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LAURA BURRIESCI

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MASON AVE BUILDING B- 2ND FLOOR
STATEN ISLAND NY
10305-3408
US

IV. Provider business mailing address

8909 BAY 16TH ST APT B1
BROOKLYN NY
11214-5923
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-1271
  • Fax: 718-226-1247
Mailing address:
  • Phone: 347-628-8862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number013497
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: