Provider Demographics
NPI:1982234761
Name:WADSWORTH, LUISANNA SOTO (PA)
Entity Type:Individual
Prefix:
First Name:LUISANNA
Middle Name:SOTO
Last Name:WADSWORTH
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 1:340 MONTAGE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1707
Mailing Address - Country:US
Mailing Address - Phone:570-346-3686
Mailing Address - Fax:
Practice Address - Street 1:340 MONTAGE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1707
Practice Address - Country:US
Practice Address - Phone:570-346-3686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024613363A00000X
PAMA062659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant