MEDICARE: MS. LISA CAMILLE PERSICO PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	018258	NY

General Provider Information

NPI Number	:	1114315975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA CAMILLE PERSICO PA

Provider Business Mailing Address
First Line	:	3612 E TREMONT AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-2039
Country	:	US
Telephone Number	:	718-409-9494
Fax Number	:	718-824-8026

Provider Business Practice Location Address
First Line	:	3612 E TREMONT AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-2039
Country	:	US
Telephone Number	:	718-409-9494
Fax Number	:	718-824-8026

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2015
Last Update Date	:	01/02/2015

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