Healthcare Provider Details

I. General information

NPI: 1255828992
Provider Name (Legal Business Name): DAVID HUGH LIWANAG REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SEAVIEW AVE
STATEN ISLAND NY
10305-3409
US

IV. Provider business mailing address

777 SEAVIEW AVE
STATEN ISLAND NY
10305-3409
US

V. Phone/Fax

Practice location:
  • Phone: 718-234-2144
  • Fax: 718-232-5613
Mailing address:
  • Phone: 718-234-2144
  • Fax: 718-232-5613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number464191
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: