Provider Demographics
NPI:1578273306
Name:LIEDTKE, ERICA STEPHANIE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ERICA
Middle Name:STEPHANIE
Last Name:LIEDTKE
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 1:3220 HATCHET BAY DR APT 3325
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5213
Mailing Address - Country:US
Mailing Address - Phone:828-242-3444
Mailing Address - Fax:
Practice Address - Street 1:38 SHERIDAN PARK CIR STE F
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-7023
Practice Address - Country:US
Practice Address - Phone:843-757-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA4579207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine