Provider Demographics
NPI:1831395102
Name:PHAM, LIZA MARIE PATAWARAN (MD)
Entity type:Individual
Prefix:
First Name:LIZA MARIE
Middle Name:PATAWARAN
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIZA MARIE
Other - Middle Name:PATAWARAN
Other - Last Name:YLESCUPIDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1114 6TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2203
Practice Address - Country:US
Practice Address - Phone:209-576-2845
Practice Address - Fax:209-576-8842
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100406208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA100406OtherMEDICAL LIC