Provider Demographics
NPI:1780154443
Name:LIDDY, JUSTIN MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:LIDDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:716 WILSON CT
Mailing Address - Street 2:
Mailing Address - City:RIVER VALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6345
Mailing Address - Country:US
Mailing Address - Phone:201-664-2597
Mailing Address - Fax:
Practice Address - Street 1:1400 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-3618
Practice Address - Country:US
Practice Address - Phone:201-316-8431
Practice Address - Fax:201-962-9735
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00500100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant