Provider Demographics
NPI:1376515106
Name:LARUSSA, LAWRENCE (PA)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:LARUSSA
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 1:1338 RIDGE RD E
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2018
Mailing Address - Country:US
Mailing Address - Phone:585-922-2410
Mailing Address - Fax:
Practice Address - Street 1:1726 RIDGE RD E
Practice Address - Street 2:SUITE 3
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622-2157
Practice Address - Country:US
Practice Address - Phone:585-266-0770
Practice Address - Fax:585-467-5369
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ36363Medicare UPIN
NYPA0687Medicare ID - Type Unspecified