Provider Demographics
NPI:1114396777
Name:LIE, DARIA TZU (PA)
Entity type:Individual
Prefix:
First Name:DARIA
Middle Name:TZU
Last Name:LIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7330 HERITAGE VILLAGE PLAZA
Mailing Address - Street 2:#102
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:540-428-1715
Mailing Address - Fax:540-779-0028
Practice Address - Street 1:13901 METROTECH DR
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3234
Practice Address - Country:US
Practice Address - Phone:540-428-1715
Practice Address - Fax:540-779-0028
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09983363A00000X
VA0110009208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX687130OtherMEDICARE PTAN
TX682934OtherMEDICARE PTAN