Provider Demographics
NPI:1760474282
Name:MALESARDI, LOUIS (PA)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:MALESARDI
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 1:121 EILEEN WAY
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-5302
Mailing Address - Country:US
Mailing Address - Phone:516-496-4964
Mailing Address - Fax:516-997-7281
Practice Address - Street 1:121 EILEEN WAY
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-5302
Practice Address - Country:US
Practice Address - Phone:516-496-4964
Practice Address - Fax:516-496-4951
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55343Medicare UPIN