Provider Demographics
NPI:1871233007
Name:LIZIO, JESSICA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:LIZIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10203 HIGH PEAK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-1257
Mailing Address - Country:US
Mailing Address - Phone:631-905-8655
Mailing Address - Fax:
Practice Address - Street 1:10203 HIGH PEAK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-1257
Practice Address - Country:US
Practice Address - Phone:631-905-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA.4265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant