Provider Demographics
NPI:1225030752
Name:TRICKEY, LISA J (PA C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:J
Last Name:TRICKEY
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
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Mailing Address - Street 1:53-59 PUBLIC SQUARE
Mailing Address - Street 2:INTERNAL MEDICINE OF NORTHERN NEW YORK SUITE 201
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2674
Mailing Address - Country:US
Mailing Address - Phone:315-782-4950
Mailing Address - Fax:315-782-3699
Practice Address - Street 1:1340 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4541
Practice Address - Country:US
Practice Address - Phone:315-782-9003
Practice Address - Fax:315-782-9010
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0050661363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMT0345012OtherDEA
NYMT0345012OtherDEA
BB0666Medicare UPIN