Provider Demographics
NPI:1023288198
Name:LEZZO, NICHOLAS J (PA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:LEZZO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 CORLIES AVE
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-6141
Mailing Address - Country:US
Mailing Address - Phone:732-776-8535
Mailing Address - Fax:732-774-9148
Practice Address - Street 1:2102 CORLIES AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-6141
Practice Address - Country:US
Practice Address - Phone:732-776-8535
Practice Address - Fax:732-774-9148
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00187300363A00000X
NY013280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00187300OtherNJ LICENSE
NYA400056947Medicare PIN
NJ373074Medicare PIN