Provider Demographics
NPI:1255702288
Name:LIU, HAILAN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:HAILAN
Middle Name:
Last Name:LIU
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-9724
Mailing Address - Fax:215-707-3677
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-500-6348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant