Provider Demographics
NPI:1497820740
Name:SCIMONE, LAWRENCE S (PA)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:S
Last Name:SCIMONE
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 1:301 PROSPECT AVE
Mailing Address - Street 2:CLINICAL AFFILIATES OFFICE
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1807
Mailing Address - Country:US
Mailing Address - Phone:315-448-2713
Mailing Address - Fax:315-448-3548
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:CLINICAL AFFILIATES OFFICE
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-2713
Practice Address - Fax:315-448-3548
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
NY002497363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR55793Medicare UPIN
NY55509GMedicare ID - Type Unspecified
NYJ400003961Medicare PIN