Basic Information
| Provider Information | |||||||||
| NPI: | 1114253457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIU | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3311 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | LIVERMORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945507007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9254621755 | ||||||||
| FaxNumber: | 9252016295 | ||||||||
| Practice Location | |||||||||
| Address1: | 3311 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | LIVERMORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945507007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9254621755 | ||||||||
| FaxNumber: | 9252016295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2009 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN60118146 | WA | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN709195 | CA | N | Nursing Service Providers | Registered Nurse | 163WC1500X | PHN74857 | CA | N | Nursing Service Providers | Registered Nurse | Community Health | 363LA2200X | NP19114 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | AP60118946 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 9662180 | 05 | WA | MEDICAID | G8890350 | 01 | MEDICARE PTAN | OTHER |