Healthcare Provider Details

I. General information

NPI: 1568217370
Provider Name (Legal Business Name): MELANIE LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 LOS GATOS ALMADEN RD
SAN JOSE CA
95124-5417
US

IV. Provider business mailing address

4014 KELVINGTON CT
SAN JOSE CA
95121-2616
US

V. Phone/Fax

Practice location:
  • Phone: 408-377-9275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: