Provider Demographics
NPI:1154405447
Name:LIGGETT, NICOLE DIANE (OD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DIANE
Last Name:LIGGETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DIANE
Other - Last Name:BOSAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4960 WILLIAM FLYNN HWY
Mailing Address - Street 2:
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-2354
Mailing Address - Country:US
Mailing Address - Phone:724-443-5060
Mailing Address - Fax:
Practice Address - Street 1:4960 WILLIAM FLYNN HWY
Practice Address - Street 2:
Practice Address - City:ALLISON PARK
Practice Address - State:PA
Practice Address - Zip Code:15101-2354
Practice Address - Country:US
Practice Address - Phone:724-443-5060
Practice Address - Fax:724-443-5066
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017950800001Medicaid
PA178483ZBZ6Medicare PIN
PAU88863Medicare UPIN