Provider Demographics
NPI:1962495069
Name:LICARI, DAMON J (PA)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:J
Last Name:LICARI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8081 INNOVATION PARK DR STE 602
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-3270
Practice Address - Fax:571-472-3271
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2022-03-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110001250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0624Medicaid
SCGP0624Medicaid
SCQ45619Medicare UPIN