Provider Demographics
NPI:1285618140
Name:LIWANAG, LAWRENCE PERALTA (PT)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:PERALTA
Last Name:LIWANAG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 SOUTHAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-1907
Mailing Address - Country:US
Mailing Address - Phone:707-745-6144
Mailing Address - Fax:707-745-5698
Practice Address - Street 1:127 HOSPITAL DR
Practice Address - Street 2:STE 101
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2500
Practice Address - Country:US
Practice Address - Phone:707-552-8795
Practice Address - Fax:707-552-9638
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT302020OtherMEDICARE PTAN