Provider Demographics
NPI:1174629679
Name:LIBBY, ERIK (PA)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:LIBBY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 GLASTONBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4468
Mailing Address - Country:US
Mailing Address - Phone:860-652-8883
Mailing Address - Fax:860-652-8887
Practice Address - Street 1:84 GLASTONBURY BLVD
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-652-8883
Practice Address - Fax:860-652-8887
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant