Basic Information
| Provider Information | |||||||||
| NPI: | 1639779275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | LIYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 BROADWAY RM 2C319 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112065317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638310 | ||||||||
| FaxNumber: | 7186303244 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 BROADWAY RM 2C319 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112065317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638310 | ||||||||
| FaxNumber: | 7186303244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.