Basic Information
| Provider Information | |||||||||
| NPI: | 1306151675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIWONJO | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | ENANGA | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1386 N 10TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550413313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127016252 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550662848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2010 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 60498 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036134343 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.