Provider Demographics
NPI:1235725672
Name:LIEBOLD, MELISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LIEBOLD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 DORCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1616
Mailing Address - Country:US
Mailing Address - Phone:631-338-0711
Mailing Address - Fax:
Practice Address - Street 1:1500 ROUTE 112 STE A
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8055
Practice Address - Country:US
Practice Address - Phone:631-265-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY026336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program