Provider Demographics
NPI:1184640419
Name:DIRISIO, LESLIE (RPA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:DIRISIO
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 LONG POND RD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4117
Mailing Address - Country:US
Mailing Address - Phone:585-442-4141
Mailing Address - Fax:585-442-6259
Practice Address - Street 1:1561 LONG POND RD
Practice Address - Street 2:SUITE 408
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4117
Practice Address - Country:US
Practice Address - Phone:585-442-4141
Practice Address - Fax:585-442-6259
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006737363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02507835Medicaid
NY02507835Medicaid
NYJ400088375/GP 70008AMedicare PIN