Provider Demographics
NPI:1104072909
Name:SIRACUSA, LISA (RPA)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:SIRACUSA
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 SEGUINE AVE
Mailing Address - Street 2:SUITE TWO
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3730
Mailing Address - Country:US
Mailing Address - Phone:718-966-7009
Mailing Address - Fax:718-948-7514
Practice Address - Street 1:305 SEGUINE AVE
Practice Address - Street 2:SUITE TWO
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3730
Practice Address - Country:US
Practice Address - Phone:718-966-7009
Practice Address - Fax:718-948-7514
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004641363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical