Healthcare Provider Details

I. General information

NPI: 1053240986
Provider Name (Legal Business Name): EZRA QUINN LICCIARDI PARAMEDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 AIRPORT RD
BISHOP CA
93514-3603
US

IV. Provider business mailing address

42453 28TH ST W
LANCASTER CA
93536-4023
US

V. Phone/Fax

Practice location:
  • Phone: 760-872-2201
  • Fax:
Mailing address:
  • Phone: 661-609-5493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP12703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: