Provider Demographics
NPI:1417419565
Name:LIOTTA, SALVATORE J (PA)
Entity type:Individual
Prefix:MR
First Name:SALVATORE
Middle Name:J
Last Name:LIOTTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 N CRAYCROFT RD BLDG 5
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2845
Mailing Address - Country:US
Mailing Address - Phone:520-296-8500
Mailing Address - Fax:
Practice Address - Street 1:2121 N CRAYCROFT RD BLDG 5
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2845
Practice Address - Country:US
Practice Address - Phone:520-296-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7548363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1167568OtherNCCPA
AZ7548OtherARIZONA MEDICAL BOARD
AZ584017Medicaid