Provider Demographics
NPI:1902202138
Name:LIEBERMAN, MARK (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1954 KIMBALL ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4512
Mailing Address - Country:US
Mailing Address - Phone:718-859-0045
Mailing Address - Fax:
Practice Address - Street 1:890 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-4251
Practice Address - Country:US
Practice Address - Phone:718-218-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-16
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical