Healthcare Provider Details

I. General information

NPI: 1912695313
Provider Name (Legal Business Name): ERICA LIEBKNECHT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 MIZELL AVE
WINTER PARK FL
32792-4106
US

IV. Provider business mailing address

1925 MIZELL AVE STE 201
WINTER PARK FL
32792-4155
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-7931
  • Fax:
Mailing address:
  • Phone: 407-335-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9117459
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: