Provider Demographics
NPI:1184749186
Name:LIECHTY, SHELDON GARTH (PA-C)
Entity type:Individual
Prefix:
First Name:SHELDON
Middle Name:GARTH
Last Name:LIECHTY
Suffix:
Gender:M
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 1:19841 N 27TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4003
Mailing Address - Country:US
Mailing Address - Phone:623-582-6420
Mailing Address - Fax:623-582-6720
Practice Address - Street 1:19841 N 27TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4003
Practice Address - Country:US
Practice Address - Phone:623-582-6420
Practice Address - Fax:623-582-6720
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1050116OtherNCCPA