Provider Demographics
NPI:1780262642
Name:LAZO, FERNANDO A (DC)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:A
Last Name:LAZO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-4130
Mailing Address - Country:US
Mailing Address - Phone:973-986-2853
Mailing Address - Fax:
Practice Address - Street 1:375 BROADWAY
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07501-2294
Practice Address - Country:US
Practice Address - Phone:973-925-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00778200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor