Healthcare Provider Details

I. General information

NPI: 1265445894
Provider Name (Legal Business Name): LISEN LIU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13625 MAPLE AVE SUITE 201,WISDOM MEDICAL PC
FLUSHING NY
11355-3870
US

IV. Provider business mailing address

13620 38TH AVE 6E
FLUSHING NY
11354-4232
US

V. Phone/Fax

Practice location:
  • Phone: 718-939-2669
  • Fax: 718-939-2663
Mailing address:
  • Phone: 718-939-2669
  • Fax: 718-939-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number239854
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: