Provider Demographics
NPI:1609948587
Name:LICHTY, MARY BETH (PAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:LICHTY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WEAVER TOWN HOMES
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-2251
Mailing Address - Country:US
Mailing Address - Phone:304-906-5965
Mailing Address - Fax:
Practice Address - Street 1:341 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-5504
Practice Address - Country:US
Practice Address - Phone:304-292-8234
Practice Address - Fax:304-284-0133
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103568363A00000X
WV01384363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant