Provider Demographics
NPI:1114980729
Name:LAURITO, STACEY ANN (PAC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:LAURITO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14A MOCCASIN DR
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-1835
Mailing Address - Country:US
Mailing Address - Phone:732-407-8488
Mailing Address - Fax:
Practice Address - Street 1:2 DEWBERRY CT
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5655
Practice Address - Country:US
Practice Address - Phone:732-407-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00096900363A00000X
GA004835363A00000X
NY010906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q19218Medicare UPIN
080835Medicare ID - Type Unspecified