Provider Demographics
NPI:1588789754
Name:LAZO, RODERICK (PA)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:LAZO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CRAVEN RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4201
Mailing Address - Country:US
Mailing Address - Phone:760-736-4125
Mailing Address - Fax:
Practice Address - Street 1:400 CRAVEN RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4201
Practice Address - Country:US
Practice Address - Phone:760-736-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant