Provider Demographics
NPI:1346621885
Name:LICKTEIG, ERIK JAMES (PA)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:JAMES
Last Name:LICKTEIG
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215B STATION ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6304
Mailing Address - Country:US
Mailing Address - Phone:910-577-2334
Mailing Address - Fax:910-577-2363
Practice Address - Street 1:215B STATION ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6304
Practice Address - Country:US
Practice Address - Phone:910-577-2334
Practice Address - Fax:910-577-2363
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001012618363A00000X
MI5601008572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant