Healthcare Provider Details

I. General information

NPI: 1720657638
Provider Name (Legal Business Name): STEPHANIE LIU PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 03/06/2022
Certification Date: 03/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 ARLINGTON BLVD STE 410
FAIRFAX VA
22031-4632
US

IV. Provider business mailing address

11350 MCCORMICK RD EXECUTIVE PLAZA 1, STE. 501
HUNT VALLEY MD
21031
US

V. Phone/Fax

Practice location:
  • Phone: 703-738-4331
  • Fax:
Mailing address:
  • Phone: 703-914-8000
  • Fax: 410-329-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007808
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: