Provider Demographics
NPI:1669786174
Name:LIEUALLEN, EMILY A (DO)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:LIEUALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 FORD RD
Mailing Address - Street 2:
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-2009
Mailing Address - Country:US
Mailing Address - Phone:475-750-4045
Mailing Address - Fax:475-754-1585
Practice Address - Street 1:STRAWBERRY WILDERNESS CLINIC
Practice Address - Street 2:180 FORD RD.
Practice Address - City:JOHN DAY
Practice Address - State:OR
Practice Address - Zip Code:97845
Practice Address - Country:US
Practice Address - Phone:541-575-0404
Practice Address - Fax:541-575-4158
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO164168207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1669786174Medicaid