Provider Demographics
NPI:1700022845
Name:NICKELSBERG, LIBERTY (CRNA)
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:NICKELSBERG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LIBERTY
Other - Middle Name:
Other - Last Name:TAMBASACAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2421
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:TOWER 3
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-3948
Practice Address - Fax:215-254-2599
Is Sole Proprietor?:No
Enumeration Date:2008-12-19
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN528329L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN528329LOtherCRNA LICENSE