Basic Information
| Provider Information | |||||||||
| NPI: | 1972769578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEDESCO | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | TAYLOR | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 NORTHERN BLVD. | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167232663 | ||||||||
| FaxNumber: | 5163257192 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 NORTHERN BLVD. | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167232663 | ||||||||
| FaxNumber: | 5163257192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2008 | ||||||||
| LastUpdateDate: | 06/04/2015 | ||||||||
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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 | 363AS0400X | 012605-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 012605 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.