Provider Demographics
NPI:1710948450
Name:MARINO, LIANA LOURDES (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LIANA
Middle Name:LOURDES
Last Name:MARINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LIANA
Other - Middle Name:LOURDES
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:6780 INDIANA AVE. #110
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:909-796-9294
Mailing Address - Fax:
Practice Address - Street 1:6780 INDIANA AVE. #110
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-682-1622
Practice Address - Fax:951-682-5902
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18166363AM0700X
CAA67841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical