Provider Demographics
NPI:1396060349
Name:LIAO, SELENA (MD)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:LIAO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 TIJERAS AVE NE STE 22
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4749
Mailing Address - Country:US
Mailing Address - Phone:505-848-3124
Mailing Address - Fax:
Practice Address - Street 1:1020 TIJERAS AVE NE STE 22
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4749
Practice Address - Country:US
Practice Address - Phone:505-848-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0542207Y00000X
390200000X
ORPG168875207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program