Provider Demographics
NPI:1528093341
Name:LIBERACE, AMY BURGESS (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:BURGESS
Last Name:LIBERACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 890195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0195
Mailing Address - Country:US
Mailing Address - Phone:336-547-1877
Mailing Address - Fax:
Practice Address - Street 1:25 W WATER ST
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-3624
Practice Address - Country:US
Practice Address - Phone:540-433-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103896363A00000X
VA0110002750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759460Medicare ID - Type UnspecifiedMEDICARE
X36987Medicare UPIN