Healthcare Provider Details

I. General information

NPI: 1114299245
Provider Name (Legal Business Name): JOSHUA STEPHEN LIES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 MARSHCREEK LN UNIT 102
NAPLES FL
34119-7949
US

IV. Provider business mailing address

2610 MARSHCREEK LN UNIT 102
NAPLES FL
34119-7949
US

V. Phone/Fax

Practice location:
  • Phone: 239-596-1930
  • Fax:
Mailing address:
  • Phone: 239-596-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9106373
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: