Provider Demographics
NPI:1790137057
Name:LI, EDMUND (PA)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 S WHITE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2073
Mailing Address - Country:US
Mailing Address - Phone:408-729-4290
Mailing Address - Fax:
Practice Address - Street 1:728 PACIFIC AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-4457
Practice Address - Country:US
Practice Address - Phone:415-956-8321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA53566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant