Provider Demographics
NPI:1073776258
Name:WU, LIANG (MD)
Entity type:Individual
Prefix:
First Name:LIANG
Middle Name:
Last Name:WU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 E LOUISE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6303
Mailing Address - Country:US
Mailing Address - Phone:208-999-0356
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6303
Practice Address - Country:US
Practice Address - Phone:208-999-0356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.094784207R00000X
ORMD160974207RN0300X
IDM-11883207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1073776258Medicaid
IDM-11883Medicaid