Provider Demographics
NPI:1871129957
Name:LIU, SHAN (NP)
Entity type:Individual
Prefix:DR
First Name:SHAN
Middle Name:
Last Name:LIU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LORETTA DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-5818
Mailing Address - Country:US
Mailing Address - Phone:516-513-4579
Mailing Address - Fax:
Practice Address - Street 1:13421 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4527
Practice Address - Country:US
Practice Address - Phone:718-886-5253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309244-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health