Provider Demographics
NPI:1942840913
Name:LORUSSO, JENNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:LORUSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 KENNEDY CT
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-1242
Mailing Address - Country:US
Mailing Address - Phone:716-989-7016
Mailing Address - Fax:
Practice Address - Street 1:4893 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4698
Practice Address - Country:US
Practice Address - Phone:716-608-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024587363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical