Provider Demographics
NPI:1225701873
Name:MASTRACCO, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MASTRACCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MAPLE AVE EXT
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7411
Mailing Address - Country:US
Mailing Address - Phone:518-770-7636
Mailing Address - Fax:518-842-0905
Practice Address - Street 1:131 MAPLE AVE EXT
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7411
Practice Address - Country:US
Practice Address - Phone:518-770-7636
Practice Address - Fax:518-842-0905
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
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