Provider Demographics
NPI:1659873776
Name:CARROLL, LIANNA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LIANNA
Middle Name:MARIE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LIANNA
Other - Middle Name:MARIE
Other - Last Name:FERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1026 UNION ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224
Mailing Address - Country:US
Mailing Address - Phone:716-712-0851
Mailing Address - Fax:716-712-0853
Practice Address - Street 1:1026 UNION ROAD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224
Practice Address - Country:US
Practice Address - Phone:716-712-0851
Practice Address - Fax:716-712-0853
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY022202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05215581Medicaid