Provider Demographics
NPI:1932112778
Name:CICO, LISA A (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CICO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-6278
Mailing Address - Fax:315-464-6365
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-8224
Practice Address - Fax:315-464-2187
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-04-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY375214163W00000X
NY302361363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03507462Medicaid