Provider Demographics
NPI:1689220063
Name:SUNG, LIZA SHINAE (AC-PNP)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:SHINAE
Last Name:SUNG
Suffix:
Gender:F
Credentials:AC-PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 MONTROSE AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-4318
Mailing Address - Country:US
Mailing Address - Phone:818-331-4396
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-660-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005822363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics