Healthcare Provider Details

I. General information

NPI: 1578273306
Provider Name (Legal Business Name): ERICA STEPHANIE LIEDTKE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 SHERIDAN PARK CIR STE F
BLUFFTON SC
29910-7023
US

IV. Provider business mailing address

3220 HATCHET BAY DR APT 3325
CHARLESTON SC
29414-5213
US

V. Phone/Fax

Practice location:
  • Phone: 843-757-6744
  • Fax:
Mailing address:
  • Phone: 828-242-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberPA4579
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: