Healthcare Provider Details

I. General information

NPI: 1750709978
Provider Name (Legal Business Name): GWENDOLYN Z LIEB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GWENDOLYN Z GOTTLIEB MD

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W COWLES ST
FAIRBANKS AK
99701-5926
US

IV. Provider business mailing address

900 5TH AVE S UNIT 100
EDMONDS WA
98020-4036
US

V. Phone/Fax

Practice location:
  • Phone: 907-451-6682
  • Fax:
Mailing address:
  • Phone: 206-660-0395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60469767
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number121743
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: