Basic Information
| Provider Information | |||||||||
| NPI: | 1265198030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEBOLD | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 MACK BLVD FL 4 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181035622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846292282 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 COMMERCE BLVD | ||||||||
| Address2: | |||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183606214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704247390 | ||||||||
| FaxNumber: | 5704247395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2021 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP024724 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | SP024724 | 01 | PA | STATE LICENSE | OTHER |