MEDICARE: LISA J TARSON :PN

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	164W00000X	Licensed Practical Nurse	266960-1	NY

General Provider Information

NPI Number	:	1679849509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA J TARSON :PN

Provider Business Mailing Address
First Line	:	276 N EDWARDS AVE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13206-2222
Country	:	US
Telephone Number	:	315-432-5636
Fax Number	:

Provider Business Practice Location Address
First Line	:	276 N EDWARDS AVE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13206-2222
Country	:	US
Telephone Number	:	315-432-5636
Fax Number	:

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

Provider Enumeration Date	:	03/26/2012
Last Update Date	:	03/26/2012

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