Basic Information
| Provider Information | |||||||||
| NPI: | 1891174991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | SHIAN | ||||||||
| MiddleName: | LIU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIU | ||||||||
| OtherFirstName: | SHIAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | NMRTC 29 PALMS | ||||||||
| Address2: | 1145 STURGIS ROAD | ||||||||
| City: | TWENTYNINE PALMS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922788275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608302070 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | DEPARTMENT OF ORTHOPAEDIC SURGERY, NAVAL MEDICAL CTR | ||||||||
| Address2: | 34800 BOB WILSON DRIVE, SUITE 112 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921345000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197445332 | ||||||||
| FaxNumber: | 6195328467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | Y | Other Service Providers | Military Health Care Provider |
No ID Information.