Provider Demographics
NPI:1942780382
Name:LIEBERMAN, DOUGLAS JASON
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JASON
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 EARLY FROST AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2623
Mailing Address - Country:US
Mailing Address - Phone:702-577-8176
Mailing Address - Fax:
Practice Address - Street 1:5523 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-2312
Practice Address - Country:US
Practice Address - Phone:702-463-4050
Practice Address - Fax:702-463-7881
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57640363L00000X
CT008028363L00000X
NV812736363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner