Provider Demographics
NPI:1417499815
Name:LAROSA, TAYLOR (PA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:LAROSA
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:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-0431
Mailing Address - Country:US
Mailing Address - Phone:631-664-9543
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST # J130
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-3000
Practice Address - Fax:212-746-8402
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020407363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical