Provider Demographics
NPI:1265198030
Name:LIEBOLD, IAN M (CRNP)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:M
Last Name:LIEBOLD
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-629-2282
Mailing Address - Fax:
Practice Address - Street 1:600 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-6214
Practice Address - Country:US
Practice Address - Phone:570-424-7390
Practice Address - Fax:570-424-7395
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP024724363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP024724OtherSTATE LICENSE