Provider Demographics
NPI:1386676203
Name:VENUTO, LISA (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VENUTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 GRIDER ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3021
Mailing Address - Country:US
Mailing Address - Phone:716-898-4803
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026799601OtherEXCELLUS UNIVERA
NY005702421OtherHEALTH NOW
NY01988334Medicaid
NY9512092OtherINDEPENDENT HEALTH
NYS97006Medicare UPIN
NY00026799601OtherEXCELLUS UNIVERA
NYBB7708Medicare PIN