Healthcare Provider Details

I. General information

NPI: 1457907974
Provider Name (Legal Business Name): KRISTEN NICOLE LIEBIG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11782 SW BARNES RD STE 300
PORTLAND OR
97225-5933
US

IV. Provider business mailing address

11782 SW BARNES RD STE 300
PORTLAND OR
97225-5933
US

V. Phone/Fax

Practice location:
  • Phone: 503-214-5200
  • Fax: 503-906-6613
Mailing address:
  • Phone: 503-214-5200
  • Fax: 503-906-6613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA221765
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: