Provider Demographics
NPI:1083665608
Name:LASTER, AVI S (PA)
Entity Type:Individual
Prefix:MR
First Name:AVI
Middle Name:S
Last Name:LASTER
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 1:651 W MOUNT PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-1600
Mailing Address - Country:US
Mailing Address - Phone:973-251-1086
Mailing Address - Fax:973-251-1109
Practice Address - Street 1:160 N MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1912
Practice Address - Country:US
Practice Address - Phone:845-685-0487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008653363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS47462Medicare UPIN