Provider Demographics
NPI:1013671700
Name:LICCIARDONE, ERIKA (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:LICCIARDONE
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 1:438 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1236
Mailing Address - Country:US
Mailing Address - Phone:570-507-4761
Mailing Address - Fax:
Practice Address - Street 1:1099 S TOWNSHIP BLVD
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3247
Practice Address - Country:US
Practice Address - Phone:570-602-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical