=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760587125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILIO LASTARRIA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 12/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 158 NORTH ST
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-719-0066
-----------------------------------------------------
Fax | 315-719-0373
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 MASON ST SUITE 214
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-1133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-230-5646
-----------------------------------------------------
Fax | 315-230-5645
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 74228
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 173332
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------