MEDICARE: FATAI LASISI

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	343900000X	Non-emergency Medical Transport (VAN)	668842755	NY

General Provider Information

NPI Number	:	1174979850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATAI LASISI

Provider Business Mailing Address
First Line	:	13801 SPRINGFIELD BLVD
Second Line	:
City	:	SPRINGFIELD GARDENS
State	:	NY
Zip	:	11413-2632
Country	:	US
Telephone Number	:	718-723-7269
Fax Number	:	718-723-7262

Provider Business Practice Location Address
First Line	:	13801 SPRINGFIELD BLVD
Second Line	:
City	:	SPRINGFIELD GARDENS
State	:	NY
Zip	:	11413-2632
Country	:	US
Telephone Number	:	718-723-7269
Fax Number	:	718-723-7262

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

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	05/11/2016

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Directions to “ FATAI LASISI ” Practice Location

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