Provider Demographics
NPI:1689212482
Name:LICCIARDELLO, MEGHAN (PA)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:LICCIARDELLO
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 1:300 HARDING BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2474
Mailing Address - Country:US
Mailing Address - Phone:916-390-1347
Mailing Address - Fax:
Practice Address - Street 1:1451 RIVER PARK DR STE 260
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4504
Practice Address - Country:US
Practice Address - Phone:650-826-2945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant