Healthcare Provider Details

I. General information

NPI: 1144690405
Provider Name (Legal Business Name): MATTHEW WATKINS LAZAR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3941 50TH AVE 2ND FL
SUNNYSIDE NY
11104-4108
US

IV. Provider business mailing address

3941 50TH AVE 2ND FL
SUNNYSIDE NY
11104-4108
US

V. Phone/Fax

Practice location:
  • Phone: 904-228-8611
  • Fax:
Mailing address:
  • Phone: 904-228-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019172
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: