Healthcare Provider Details

I. General information

NPI: 1548668783
Provider Name (Legal Business Name): NOEL LIWANAG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4922 LASALLE RD
HYATTSVILLE MD
20782-3302
US

IV. Provider business mailing address

4922 LASALLE RD
HYATTSVILLE MD
20782-3302
US

V. Phone/Fax

Practice location:
  • Phone: 31-864-2333
  • Fax:
Mailing address:
  • Phone: 31-864-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number22913
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: