Provider Demographics
NPI:1659396729
Name:LIUZZA, KIM LAUCKHARDT (PA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LAUCKHARDT
Last Name:LIUZZA
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 1:91 GLENEIDA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-1222
Mailing Address - Country:US
Mailing Address - Phone:845-228-7000
Mailing Address - Fax:845-228-5485
Practice Address - Street 1:91 GLENEIDA AVE
Practice Address - Street 2:STE A
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-1222
Practice Address - Country:US
Practice Address - Phone:845-228-7000
Practice Address - Fax:845-228-5485
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002937363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1659396729Medicare NSC