Provider Demographics
NPI:1942887393
Name:DEROSA, LISA ANN (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:DEROSA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PALACE CT
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-3131
Mailing Address - Country:US
Mailing Address - Phone:631-905-6771
Mailing Address - Fax:
Practice Address - Street 1:6 PALACE CT
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-3131
Practice Address - Country:US
Practice Address - Phone:631-905-6771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant