Provider Demographics
NPI:1003860453
Name:LOMELI, LIBERTY (PA-C)
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:LOMELI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 EAST CENTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6331
Mailing Address - Country:US
Mailing Address - Phone:559-734-4700
Mailing Address - Fax:559-734-1247
Practice Address - Street 1:1107 WEST POPLAR AVE.
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-5839
Practice Address - Country:US
Practice Address - Phone:559-781-7242
Practice Address - Fax:559-793-3542
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant