Healthcare Provider Details

I. General information

NPI: 1790268043
Provider Name (Legal Business Name): MELISSA JOY LIEBMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 05/27/2023
Certification Date: 05/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

24 DALTON WAY
HOLLAND PA
18966-5304
US

V. Phone/Fax

Practice location:
  • Phone: 212-304-6172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022569
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: