Provider Demographics
NPI:1215031893
Name:LARICCIA, MICHAEL ANTHONY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:LARICCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 WEST LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-3849
Mailing Address - Country:US
Mailing Address - Phone:814-833-2022
Mailing Address - Fax:814-838-1223
Practice Address - Street 1:10081 RIDGE RD
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:PA
Practice Address - Zip Code:16417
Practice Address - Country:US
Practice Address - Phone:814-774-2630
Practice Address - Fax:814-774-2719
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT000694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA068733RYZMedicare ID - Type Unspecified
PA043428R5DMedicare ID - Type Unspecified