=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750653044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN LAPORTA PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2012
-----------------------------------------------------
Last Update Date | 02/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 E STATE ST
-----------------------------------------------------
City | GLOVERSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12078-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-773-4205
-----------------------------------------------------
Fax | 518-775-4283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 E STATE ST
-----------------------------------------------------
City | GLOVERSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12078-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-775-4264
-----------------------------------------------------
Fax | 518-775-4283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 015425
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------