Provider Demographics
NPI:1699831057
Name:LIPTRAP, ROY (PA)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:
Last Name:LIPTRAP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 TOMPKINS ST
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34450-4138
Mailing Address - Country:US
Mailing Address - Phone:352-341-3501
Mailing Address - Fax:352-341-3509
Practice Address - Street 1:502 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4720
Practice Address - Country:US
Practice Address - Phone:352-341-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0003426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290635000Medicaid
FLS59745Medicare UPIN
FL290635000Medicaid