Provider Demographics
NPI:1558122622
Name:LEIBFREID, ELIZABETH ANN (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:LEIBFREID
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-757-3840
Mailing Address - Fax:
Practice Address - Street 1:1601 HADDON AVE STE A1
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3109
Practice Address - Country:US
Practice Address - Phone:856-757-3840
Practice Address - Fax:856-757-3519
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00832900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1005227Medicaid