Provider Demographics
NPI:1760804512
Name:LIZEWSKI, COLLEEN MARGARET (PA-C)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARGARET
Last Name:LIZEWSKI
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 1:40 W FRACK ST
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931-1719
Mailing Address - Country:US
Mailing Address - Phone:570-794-6123
Mailing Address - Fax:570-794-6124
Practice Address - Street 1:40 W FRACK ST
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931-1719
Practice Address - Country:US
Practice Address - Phone:570-794-6123
Practice Address - Fax:570-794-6124
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004346363A00000X
NC0010-14034363AM0700X
PAMA055811363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant