Healthcare Provider Details

I. General information

NPI: 1235640319
Provider Name (Legal Business Name): MRS. BRENDA NGUYEN LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 06/11/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8375 NW 53RD ST
DORAL FL
33166-4611
US

IV. Provider business mailing address

8375 NW 53RD ST
DORAL FL
33166-4611
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-8644
  • Fax:
Mailing address:
  • Phone: 305-243-8644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110606
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: