Provider Demographics
NPI:1346620069
Name:LIECHTY, AMANDA J (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:LIECHTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:J
Other - Last Name:COPPINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4927 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4813
Mailing Address - Country:US
Mailing Address - Phone:813-480-2892
Mailing Address - Fax:
Practice Address - Street 1:4927 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4813
Practice Address - Country:US
Practice Address - Phone:813-480-2892
Practice Address - Fax:134-285-8848
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058558363A00000X
363A00000X
FLPA9116134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032657000001Medicaid
PA546523OtherMEDICARE