=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750771739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERINA LIE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2015
-----------------------------------------------------
Last Update Date | 11/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 TRAEGER AVE STE 310
-----------------------------------------------------
City | SAN BRUNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94066-3048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-757-9494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 HARRISON ST FL 7
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94612-3466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-625-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207NP0225X
-----------------------------------------------------
Taxonomy Name | Pediatric Dermatology Physician
-----------------------------------------------------
License Number | A178222
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | A178222
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------