Provider Demographics
NPI:1881391852
Name:LI, QIYAN
Entity type:Individual
Prefix:
First Name:QIYAN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 VISTA GRANDE
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1136
Mailing Address - Country:US
Mailing Address - Phone:510-439-8138
Mailing Address - Fax:
Practice Address - Street 1:370 BRIDGE PKWY STE 2A
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94065-1036
Practice Address - Country:US
Practice Address - Phone:510-918-8138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19679171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist