Provider Demographics
NPI:1366408775
Name:DURANDETTO, LISA A (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:DURANDETTO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:325 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8243
Practice Address - Country:US
Practice Address - Phone:716-630-1146
Practice Address - Fax:716-817-1727
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF304142363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ43696Medicare UPIN
NYRA661Medicare ID - Type Unspecified