Healthcare Provider Details

I. General information

NPI: 1801712872
Provider Name (Legal Business Name): JACK LIU FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 S MILL AVE STE 212
TEMPE AZ
85281-5664
US

IV. Provider business mailing address

3700 E GIDEON WAY
GILBERT AZ
85296-2977
US

V. Phone/Fax

Practice location:
  • Phone: 480-332-8446
  • Fax:
Mailing address:
  • Phone: 480-703-2530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number269640
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: