Healthcare Provider Details

I. General information

NPI: 1942037163
Provider Name (Legal Business Name): MALAIYA ILENE ERASO LIWAG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 E WARNER RD STE 115
GILBERT AZ
85296-3133
US

IV. Provider business mailing address

6640 E MCDOWELL RD APT 3006
SCOTTSDALE AZ
85257-3153
US

V. Phone/Fax

Practice location:
  • Phone: 480-590-3915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-23091
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: