Provider Demographics
NPI:1124596408
Name:LIU, CAMMIE C (MMS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:CAMMIE
Middle Name:C
Last Name:LIU
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 S DELANO CT E APT 814
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3466
Mailing Address - Country:US
Mailing Address - Phone:310-907-6406
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9509
Practice Address - Country:US
Practice Address - Phone:815-300-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant