Provider Demographics
NPI:1356837702
Name:LIU, JUSTIN M (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:LIU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1300 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2031
Mailing Address - Country:US
Mailing Address - Phone:631-727-6308
Mailing Address - Fax:631-369-8129
Practice Address - Street 1:31 MAIN RD STE 3
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-727-6308
Practice Address - Fax:631-369-8129
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY022149-1363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical