Basic Information
| Provider Information | |||||||||
| NPI: | 1467601401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEDESCO | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PILOZZI | ||||||||
| OtherFirstName: | LARISSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2800 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066064201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032682882 | ||||||||
| FaxNumber: | 2034523099 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 WESTCHESTER AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106042906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149461010 | ||||||||
| FaxNumber: | 9149461025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1688 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 1688 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 010822-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.