Provider Demographics
NPI:1114499787
Name:LANZELOTTI, BLISS NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BLISS
Middle Name:NICOLE
Last Name:LANZELOTTI
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 1:161 DALY RD
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 DALY RD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-6335
Practice Address - Country:US
Practice Address - Phone:516-581-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023091363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical