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General NPI Number Information
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NPI Number | 1780154443
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Entity Type | Individual
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Provider Name | JUSTIN MICHAEL LIDDY PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/26/2018
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Last Update Date | 11/26/2018
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Provider Practice Location Address
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Address Line | 1400 MACARTHUR BLVD
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City | MAHWAH
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State | NJ
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Zip | 07430-3618
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Country | US
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Telephone | 201-316-8431
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Fax | 201-962-9735
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Provider Business Mailing Address
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Address Line | 716 WILSON CT
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City | RIVER VALE
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State | NJ
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Zip | 07675-6345
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Country | US
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Telephone | 201-664-2597
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 25MP00500100
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License Number State | NJ
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