Provider Demographics
NPI:1063969061
Name:LASARSO, NICHOLAS ANGELO (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANGELO
Last Name:LASARSO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1702
Mailing Address - Country:US
Mailing Address - Phone:518-926-2075
Mailing Address - Fax:518-926-2020
Practice Address - Street 1:2 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1702
Practice Address - Country:US
Practice Address - Phone:518-926-2075
Practice Address - Fax:518-926-2020
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4697225100000X, 2251S0007X, 2251X0800X
NY047240-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400335825Medicare PIN