Provider Demographics
NPI:1023212842
Name:LICAJ, SKERDILAID (PA)
Entity Type:Individual
Prefix:
First Name:SKERDILAID
Middle Name:
Last Name:LICAJ
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 1:7603 DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4153
Mailing Address - Country:US
Mailing Address - Phone:843-692-9099
Mailing Address - Fax:
Practice Address - Street 1:1714 HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4041
Practice Address - Country:US
Practice Address - Phone:843-545-7200
Practice Address - Fax:843-545-5742
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant