Basic Information
| Provider Information | |||||||||
| NPI: | 1063867711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIYANTO | ||||||||
| FirstName: | BRIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 MARENGO ST # C4E100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331352 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 2051 MARENGO ST # C4E100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234091000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2016 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | A143981 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.