Provider Demographics
NPI:1720161318
Name:WISOTSKY, LAURIE K (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:K
Last Name:WISOTSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:K
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 21686
Mailing Address - Street 2:C/O UNITED SURGICAL ASSISTANTS, INC.
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-1686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12880 COMMODITY PL
Practice Address - Street 2:C/O UNITED SURGICAL ASSISTANTS, INC.
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3101
Practice Address - Country:US
Practice Address - Phone:877-872-5788
Practice Address - Fax:866-698-7272
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103684363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA768XMedicare PIN
FLAA768ZMedicare PIN
S09746Medicare UPIN
FLAA768YMedicare PIN