Provider Demographics
NPI:1003490905
Name:LI, FANG
Entity Type:Individual
Prefix:
First Name:FANG
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 RANDALL DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-5529
Mailing Address - Country:US
Mailing Address - Phone:757-214-8327
Mailing Address - Fax:
Practice Address - Street 1:853 JEFFERSON AVE STE E102
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2804
Practice Address - Country:US
Practice Address - Phone:901-448-2531
Practice Address - Fax:901-448-4701
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program