Provider Demographics
NPI:1255449948
Name:SOUSOU, LISA J (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:SOUSOU
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 1:239 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1228
Mailing Address - Country:US
Mailing Address - Phone:315-598-4715
Mailing Address - Fax:315-598-4733
Practice Address - Street 1:522 S 4TH ST STE 500
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2936
Practice Address - Country:US
Practice Address - Phone:315-598-4740
Practice Address - Fax:315-598-4728
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP43961Medicare UPIN
NYCC9613Medicare ID - Type Unspecified