Basic Information
| Provider Information | |||||||||
| NPI: | 1306889621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263462455 | ||||||||
| FaxNumber: | 6266393005 | ||||||||
| Practice Location | |||||||||
| Address1: | 877 E. SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917662009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096207769 | ||||||||
| FaxNumber: | 8777786944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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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 | 207Q00000X | PA15055 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | EFF:2/20/13-ELB | 05 | CA | MEDICAID | EFF:2/20/13-NLB | 05 | CA | MEDICAID | EFF:2/20/13-WILMINGT | 05 | CA | MEDICAID | P01272652/DU4032 | 01 | CA | RAILROAD MEDICARE | OTHER | PA15055 | 01 | CA | MEDI-CAL | OTHER | EFF:3/11/13-ONTARIO | 05 | CA | MEDICAID | P01272674 | 01 | CA | RAILROAD MEDICARE- DU4034 | OTHER | PA15055 | 05 | CA | MEDICAID |