Healthcare Provider Details

I. General information

NPI: 1770182867
Provider Name (Legal Business Name): YIWEN LI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13211 SE 189TH PL
RENTON WA
98058-8053
US

IV. Provider business mailing address

13211 SE 189TH PL
RENTON WA
98058-8053
US

V. Phone/Fax

Practice location:
  • Phone: 415-568-8835
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberMC55294
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: