Provider Demographics
NPI:1205813615
Name:LIDDLE, ALFRED HENRY (PA)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:HENRY
Last Name:LIDDLE
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 1:2 WAKE ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4241
Mailing Address - Country:US
Mailing Address - Phone:401-334-3105
Mailing Address - Fax:
Practice Address - Street 1:2 WAKE ROBIN RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4241
Practice Address - Country:US
Practice Address - Phone:401-334-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S89484Medicare UPIN