Healthcare Provider Details

I. General information

NPI: 1528093341
Provider Name (Legal Business Name): AMY BURGESS LIBERACE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W WATER ST
HARRISONBURG VA
22801-3624
US

IV. Provider business mailing address

PO BOX 890195
CHARLOTTE NC
28289-0195
US

V. Phone/Fax

Practice location:
  • Phone: 540-433-5431
  • Fax:
Mailing address:
  • Phone: 336-547-1877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103896
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002750
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: