Provider Demographics
NPI:1255977856
Name:LACSON, CHRISTIAN SHAYNE LARGO
Entity type:Individual
Prefix:
First Name:CHRISTIAN SHAYNE
Middle Name:LARGO
Last Name:LACSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 CORNISH AVE APT 4K
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3710
Mailing Address - Country:US
Mailing Address - Phone:662-230-0895
Mailing Address - Fax:
Practice Address - Street 1:9218 165TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-1104
Practice Address - Country:US
Practice Address - Phone:718-725-0044
Practice Address - Fax:718-725-0880
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty