Provider Demographics
NPI:1306889621
Name:LI, LAWRENCE D (PA-C)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:D
Last Name:LI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:877 E. SECOND STREET
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2009
Practice Address - Country:US
Practice Address - Phone:909-620-7769
Practice Address - Fax:877-778-6944
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF:2/20/13-ELBMedicaid
CAEFF:2/20/13-NLBMedicaid
CAEFF:2/20/13-WILMINGTMedicaid
CAP01272652/DU4032OtherRAILROAD MEDICARE
CAPA15055OtherMEDI-CAL
CAEFF:3/11/13-ONTARIOMedicaid
CAP01272674OtherRAILROAD MEDICARE- DU4034
CAPA15055Medicaid
CAEFF:2/20/13-ELBMedicaid
CAPA15055OtherMEDI-CAL
CAEFF:3/11/13-ONTARIOMedicaid
CAWPA15055HMedicare PIN
CAWPA15055FMedicare PIN
CAWPA15055DMedicare PIN
CAWPA15055CMedicare PIN
CAWPA15055IMedicare PIN
CACL500XMedicare PIN
CACL500VMedicare PIN
CAP01272652/DU4032OtherRAILROAD MEDICARE
CAEFF:2/20/13-WILMINGTMedicaid
CAEFF:3/11/13 MORENO VMedicare PIN