Healthcare Provider Details

I. General information

NPI: 1841182334
Provider Name (Legal Business Name): SHIRLEY LIU
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 LINCOLN BLVD
MARINA DEL REY CA
90292-6306
US

IV. Provider business mailing address

4650 LINCOLN BLVD
MARINA DEL REY CA
90292-6306
US

V. Phone/Fax

Practice location:
  • Phone: 310-823-8911
  • Fax:
Mailing address:
  • Phone: 310-423-2600
  • Fax: 310-423-8397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number66710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: