Provider Demographics
NPI:1548417926
Name:MAXA, LIANA
Entity Type:Individual
Prefix:
First Name:LIANA
Middle Name:
Last Name:MAXA
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 1:1455 BATTERSBY AVE
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3634
Mailing Address - Country:US
Mailing Address - Phone:253-426-6341
Mailing Address - Fax:360-697-2514
Practice Address - Street 1:1455 BATTERSBY AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3634
Practice Address - Country:US
Practice Address - Phone:253-426-6341
Practice Address - Fax:360-697-2514
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60251154207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2015406Medicaid