Provider Demographics
NPI:1003188814
Name:LASKY, JODI (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:
Last Name:LASKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-2854
Mailing Address - Country:US
Mailing Address - Phone:203-565-4728
Mailing Address - Fax:
Practice Address - Street 1:26 WESTPORT DR
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-2854
Practice Address - Country:US
Practice Address - Phone:203-565-4728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001139363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical