Provider Demographics
NPI:1326138488
Name:LASKO, SUSAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:LASKO
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 1:322 CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-3622
Mailing Address - Country:US
Mailing Address - Phone:831-426-9152
Mailing Address - Fax:
Practice Address - Street 1:398 S GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3099
Practice Address - Country:US
Practice Address - Phone:831-724-7616
Practice Address - Fax:861-724-7438
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31334Medicare UPIN
0PA115930Medicare ID - Type Unspecified