Provider Demographics
NPI:1457527566
Name:LANTOWSKI, AGNIESZKA (PA-C)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:LANTOWSKI
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 1:470 GOWER ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6461
Mailing Address - Country:US
Mailing Address - Phone:917-604-8657
Mailing Address - Fax:
Practice Address - Street 1:256 MASON AVE
Practice Address - Street 2:BLDG C, 3RD FLOOR
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3408
Practice Address - Country:US
Practice Address - Phone:718-226-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03596229Medicaid
NY03596229Medicaid