Provider Demographics
NPI:1497832125
Name:LISICK, DARIA ANN (PA)
Entity Type:Individual
Prefix:
First Name:DARIA
Middle Name:ANN
Last Name:LISICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5719 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1985
Mailing Address - Country:US
Mailing Address - Phone:315-251-3105
Mailing Address - Fax:315-449-9923
Practice Address - Street 1:240 RIVERSIDE DR.
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2732
Practice Address - Country:US
Practice Address - Phone:607-798-9356
Practice Address - Fax:607-797-1707
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006573363A00000X, 363AS0400X
NY006573-1363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01793411Medicaid
S44604Medicare UPIN
NY34739MMedicare ID - Type Unspecified