Provider Demographics
NPI:1740742980
Name:PROSPERO, LYDIA M (PA-C)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:PROSPERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:M
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:777 CANAL VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2825
Mailing Address - Country:US
Mailing Address - Phone:585-244-3430
Mailing Address - Fax:
Practice Address - Street 1:777 CANAL VIEW BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2825
Practice Address - Country:US
Practice Address - Phone:585-244-3430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23585363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical