Basic Information
| Provider Information | |||||||||
| NPI: | 1255828992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIWANAG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | HUGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | REGISTERED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 SEAVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182342144 | ||||||||
| FaxNumber: | 7182325613 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 SEAVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182342144 | ||||||||
| FaxNumber: | 7182325613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2018 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 464191 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2997157 | 05 | NY | MEDICAID |