Provider Demographics
NPI:1447373907
Name:LAZZARO, MYRA CELESTE (PA-C)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:CELESTE
Last Name:LAZZARO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:CELESTE
Other - Last Name:LAZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 4059
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4059
Mailing Address - Country:US
Mailing Address - Phone:973-894-1263
Mailing Address - Fax:888-972-3703
Practice Address - Street 1:695 US HIGHWAY 46
Practice Address - Street 2:SUITE 400A
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-1592
Practice Address - Country:US
Practice Address - Phone:973-894-1263
Practice Address - Fax:888-972-3703
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052978363AM0700X
NJ25MP00302000363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ548592ZJ5NMedicare PIN
NJ444681ZFN8Medicare PIN