Provider Demographics
NPI:1952946188
Name:LISKA, TARA NICOLE (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:LISKA
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 GENESEE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2696
Mailing Address - Country:US
Mailing Address - Phone:315-363-4651
Mailing Address - Fax:315-363-2821
Practice Address - Street 1:357 GENESEE ST STE 2
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2696
Practice Address - Country:US
Practice Address - Phone:315-363-4651
Practice Address - Fax:315-363-2821
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002618002255A2300X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
1190522OtherNCCPA ID NUMBER
NY004692OtherNEW YORK STATE EDUCATION DEPARTMENT
2000034224OtherBOC CERTIFICATION NUMBER