Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 047240-01 | NY |
N | 225100000X | Physical Therapist | PT4697 | ME |
N | 2251S0007X | Physical Therapist - Sports | PT4697 | ME |
N | 2251X0800X | Physical Therapist - Orthopedic | PT4697 | ME |
NPI | 1063969061 |
---|---|
Provider Name | Nicholas Angelo Lasarso |
First Address | Queensbury, NY 12804-1702 |
Second Address | Queensbury, NY 12804-1702 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2016 |
Last Update Date | 17/08/2021 |