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General NPI Number Information
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NPI Number | 1225030752
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Entity Type | Individual
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Provider Name | LISA J TRICKEY PA C
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Gender | Female
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Dates
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Enumeration Date | 08/15/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1340 WASHINGTON ST
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City | WATERTOWN
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State | NY
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Zip | 13601-4541
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Country | US
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Telephone | 315-782-9003
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Fax | 315-782-9010
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Provider Business Mailing Address
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Address Line | 53-59 PUBLIC SQUARE INTERNAL MEDICINE OF NORTHERN NEW YORK SUITE 201
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City | WATERTOWN
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State | NY
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Zip | 13601-2674
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Country | US
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Telephone | 315-782-4950
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Fax | 315-782-3699
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0050661
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License Number State | NY
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