Provider Demographics
NPI:1336184332
Name:DIRISIO, LAWRENCE P (RPA C)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:P
Last Name:DIRISIO
Suffix:
Gender:M
Credentials:RPA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 CHILI AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3425
Mailing Address - Country:US
Mailing Address - Phone:585-247-0070
Mailing Address - Fax:585-247-0075
Practice Address - Street 1:2115 CHILI AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-3425
Practice Address - Country:US
Practice Address - Phone:585-247-0070
Practice Address - Fax:585-247-0075
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R53412Medicare UPIN