Provider Demographics
NPI:1568825495
Name:LIEN, JESSICA SUZANNE KIM (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUZANNE KIM
Last Name:LIEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14000 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5713
Mailing Address - Country:US
Mailing Address - Phone:952-993-8700
Mailing Address - Fax:952-993-8516
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5713
Practice Address - Country:US
Practice Address - Phone:952-993-8700
Practice Address - Fax:952-993-8516
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR76310207W00000X
390200000X
MN67479207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568825495Medicaid