Provider Demographics
NPI:1437797347
Name:LIWAG, ERICKSON DIZON
Entity Type:Individual
Prefix:
First Name:ERICKSON
Middle Name:DIZON
Last Name:LIWAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N 6TH ST APT G
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-3203
Mailing Address - Country:US
Mailing Address - Phone:818-398-1554
Mailing Address - Fax:
Practice Address - Street 1:500 N 6TH ST APT G
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-3203
Practice Address - Country:US
Practice Address - Phone:818-398-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily