MEDICARE: SCOTT A LIBERTY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	003781	NY

General Provider Information

NPI Number	:	1053641886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT A LIBERTY PA

Provider Business Mailing Address
First Line	:	3794 STATE ROUTE 3
Second Line	:
City	:	SARANAC
State	:	NY
Zip	:	12981-3104
Country	:	US
Telephone Number	:	518-293-7302
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 HAMMOND LN
Second Line	:	SUITE 2
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-2008
Country	:	US
Telephone Number	:	518-563-5900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2009
Last Update Date	:	12/29/2009

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