Provider Demographics
NPI:1689203606
Name:KRZOS, LAUREN I
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:I
Last Name:KRZOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5013
Mailing Address - Country:US
Mailing Address - Phone:516-809-9666
Mailing Address - Fax:516-809-9665
Practice Address - Street 1:550 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5013
Practice Address - Country:US
Practice Address - Phone:516-809-9666
Practice Address - Fax:516-809-9665
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant