Provider Demographics
NPI:1124243761
Name:LIEBAU, JAMES G (ANP)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:G
Last Name:LIEBAU
Suffix:
Gender:M
Credentials:ANP
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Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:MGH LON207
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-724-6926
Mailing Address - Fax:617-724-8998
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:MGH LON207
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-6926
Practice Address - Fax:617-724-8998
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA250459363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health