Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204F00000X | Transplant Surgeon | 306134 | NY |
N | 208200000X | Surgeon | 036-100492 | IL |
N | 208600000X | Surgeon | 036-100492 | IL |
N | 2086S0102X | Surgical Critical Care | 036-100492 | IL |
N | 2086S0102X | Surgical Critical Care | 306134 | NY |
NPI | 1366488850 |
---|---|
Provider Name | Mark Dy-Liacco |
First Address | Pittsburgh, PA 15220-3704 |
Second Address | Buffalo, NY 14215-3098 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2006 |
Last Update Date | 25/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1366488850 | (05) | NC |
19PD0 | BCBS OF NC (01) | NC |
H81792 | (02) | IL |
NCW874A | MEDICARE (01) | NC |