1326148404 NPI number — MRS. LISA A SORRENTINO PA

Table of content: MRS. LISA A SORRENTINO PA (NPI 1326148404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326148404 NPI number — MRS. LISA A SORRENTINO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORRENTINO
Provider First Name:
LISA
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHILLIANS
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326148404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 NORTHPOINTE PARKWAY
Provider Second Line Business Mailing Address:
SUITE 50
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-834-1191
Provider Business Mailing Address Fax Number:
716-923-4380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1440 MAPLE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-568-3600
Provider Business Practice Location Address Fax Number:
716-923-4384
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  011299-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 011299 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000528916002 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02839196 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 197646BJ . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9514041 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00027798902 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00027798901 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000528916001 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 070209000070 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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