Provider Demographics
NPI:1710942073
Name:SPOSATO, LISA BETH (RPA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
Last Name:SPOSATO
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BREWSTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SALONGA
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2616
Mailing Address - Country:US
Mailing Address - Phone:631-807-4802
Mailing Address - Fax:
Practice Address - Street 1:60 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1578
Practice Address - Country:US
Practice Address - Phone:516-222-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011040363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03875183Medicaid