Provider Demographics
NPI:1013206622
Name:LIESMAKI, ERICA L (MD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:LIESMAKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:L
Other - Last Name:GRUNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:719-463-5600
Mailing Address - Fax:
Practice Address - Street 1:4500 E 9TH AVE
Practice Address - Street 2:STE #320
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3912
Practice Address - Country:US
Practice Address - Phone:303-322-0212
Practice Address - Fax:303-322-0208
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0051594207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46139745Medicaid
CO354097YL7XMedicare PIN