Provider Demographics
NPI:1003826157
Name:MICIK, LISA M (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MICIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1 W RIDGEWOOD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2361
Mailing Address - Country:US
Mailing Address - Phone:201-857-4200
Mailing Address - Fax:
Practice Address - Street 1:1 W RIDGEWOOD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2359
Practice Address - Country:US
Practice Address - Phone:201-857-4200
Practice Address - Fax:201-857-4199
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY010318363A00000X
NJMP00136000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant