Healthcare Provider Details

I. General information

NPI: 1346621885
Provider Name (Legal Business Name): ERIK JAMES LICKTEIG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215B STATION ST
JACKSONVILLE NC
28546-6304
US

IV. Provider business mailing address

215B STATION ST
JACKSONVILLE NC
28546-6304
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-2334
  • Fax: 910-577-2363
Mailing address:
  • Phone: 910-577-2334
  • Fax: 910-577-2363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001012618
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: