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General NPI Number Information
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NPI Number | 1174758908
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Entity Type | Individual
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Provider Name | LIZA ANTOINETTE JAIN PHU M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/22/2009
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 265 CREEK LN S
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City | JORDAN
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State | MN
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Zip | 55352-1214
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Country | US
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Telephone | 952-428-1200
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Fax | 952-428-1201
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Provider Business Mailing Address
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Address Line | 2925 CHICAGO AVE
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City | MINNEAPOLIS
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State | MN
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Zip | 55407-1321
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Country | US
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Telephone | 612-262-5000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 60116222
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036.129032
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 53359
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License Number State | MN
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