Provider Demographics
NPI:1992272694
Name:LAZARUS, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:LAZARUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 BELLMORE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-3747
Mailing Address - Country:US
Mailing Address - Phone:516-761-2634
Mailing Address - Fax:
Practice Address - Street 1:1000 N VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1000
Practice Address - Country:US
Practice Address - Phone:516-705-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022925-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022925-1OtherNEW YORK STATE LICENSE