Provider Demographics
NPI:1356454698
Name:REICHENBERGER, LIZA HOEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LIZA
Middle Name:HOEN
Last Name:REICHENBERGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:PAULINE
Other - Last Name:HOEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 AVILA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2852
Mailing Address - Country:US
Mailing Address - Phone:650-454-9951
Mailing Address - Fax:650-350-1228
Practice Address - Street 1:2900 WHIPPLE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-2843
Practice Address - Country:US
Practice Address - Phone:650-365-5996
Practice Address - Fax:650-365-0655
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002934363AM0700X
CAPA19934363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001887AMedicaid
GA97BBFXMMedicare ID - Type Unspecified
GA100001887AMedicaid