Provider Demographics
NPI:1053641886
Name:LIBERTY, SCOTT A (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:LIBERTY
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 1:3794 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:SARANAC
Mailing Address - State:NY
Mailing Address - Zip Code:12981-3104
Mailing Address - Country:US
Mailing Address - Phone:518-293-7302
Mailing Address - Fax:
Practice Address - Street 1:79 HAMMOND LN
Practice Address - Street 2:SUITE 2
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2008
Practice Address - Country:US
Practice Address - Phone:518-563-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant