Healthcare Provider Details

I. General information

NPI: 1265172282
Provider Name (Legal Business Name): JEFFREY YEN-TING LIU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 AIRWAY DR STE 203
SANTA ROSA CA
95403-1671
US

IV. Provider business mailing address

3883 AIRWAY DR STE 203
SANTA ROSA CA
95403-1671
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-5425
  • Fax:
Mailing address:
  • Phone: 707-521-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA206659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: