Healthcare Provider Details

I. General information

NPI: 1275708182
Provider Name (Legal Business Name): EMELITA DEMETILLO LIWANAG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 ODDIE BLVD
SPARKS NV
89431-3559
US

IV. Provider business mailing address

850 HARVARD WAY
RENO NV
89502-2055
US

V. Phone/Fax

Practice location:
  • Phone: 775-982-5140
  • Fax: 775-982-5141
Mailing address:
  • Phone: 775-982-5262
  • Fax: 775-982-5496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL.2736R
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13024
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: