Provider Demographics
NPI:1740373802
Name:LAROCCA-HULSEN, LISA (DPM)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:LAROCCA-HULSEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2982
Mailing Address - Country:US
Mailing Address - Phone:631-724-1166
Mailing Address - Fax:631-724-4130
Practice Address - Street 1:260 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2982
Practice Address - Country:US
Practice Address - Phone:631-724-1166
Practice Address - Fax:631-724-4130
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005415213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400005612Medicare UPIN