Provider Demographics
NPI:1770529422
Name:JAY, LIBERTY BELLE (PA-C)
Entity type:Individual
Prefix:
First Name:LIBERTY
Middle Name:BELLE
Last Name:JAY
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 1:27 S BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3406
Mailing Address - Country:US
Mailing Address - Phone:610-527-2727
Mailing Address - Fax:610-527-1588
Practice Address - Street 1:825 OLD LANCASTER RD
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3231
Practice Address - Country:US
Practice Address - Phone:610-922-2100
Practice Address - Fax:610-520-2091
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA051793Medicare ID - Type UnspecifiedPROVIDER NUMBER
PAP57604Medicare UPIN