Provider Demographics
NPI:1952829814
Name:LIEDECKE, JOHN ADRIAN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ADRIAN
Last Name:LIEDECKE
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 1:101 BAYVIEW ST APT A
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4914
Mailing Address - Country:US
Mailing Address - Phone:936-661-2198
Mailing Address - Fax:
Practice Address - Street 1:20 N SAN PEDRO RD STE 2021
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4158
Practice Address - Country:US
Practice Address - Phone:936-661-2198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program