Provider Demographics
NPI:1710160809
Name:LAZCANO, IRENE MARIANO (PT)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:MARIANO
Last Name:LAZCANO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5852 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4852
Mailing Address - Country:US
Mailing Address - Phone:718-305-2173
Mailing Address - Fax:718-305-2173
Practice Address - Street 1:308 NEPTUNE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6845
Practice Address - Country:US
Practice Address - Phone:718-615-0800
Practice Address - Fax:866-419-7618
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024082-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQQ3371Medicare PIN