Basic Information
Provider Information | |||||||||
NPI: | 1679806574 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIU | ||||||||
FirstName: | VIVIAN | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3727 NE MARTIN LUTHER KING JR BLVD | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972121112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037754931 | ||||||||
FaxNumber: | 5037887285 | ||||||||
Practice Location | |||||||||
Address1: | 3727 NE MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972121112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037754931 | ||||||||
FaxNumber: | 5037887285 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2009 | ||||||||
LastUpdateDate: | 03/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 200950113NP NMNP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 500617867 | 05 | OR |   | MEDICAID | 9664475 | 05 | WA |   | MEDICAID |