Provider Demographics
NPI:1780795344
Name:LEVY, LARISA (PA)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:LEVY
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 1:441 9TH AVE
Mailing Address - Street 2:CREDENTIALING 3RD FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1623
Mailing Address - Country:US
Mailing Address - Phone:646-680-2894
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:14015 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2557
Practice Address - Country:US
Practice Address - Phone:718-670-6400
Practice Address - Fax:718-670-6479
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYP51483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03569404Medicaid
NYG400037600Medicare PIN