Basic Information
| Provider Information | |||||||||
| NPI: | 1780795344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVY | ||||||||
| FirstName: | LARISA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 441 9TH AVE | ||||||||
| Address2: | CREDENTIALING 3RD FL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100011623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802894 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 14015 SANFORD AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113552557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186706400 | ||||||||
| FaxNumber: | 7186706479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | P51483 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03569404 | 05 | NY | MEDICAID |