Provider Demographics
NPI:1841683406
Name:LIUO, KO GENG
Entity type:Individual
Prefix:
First Name:KO GENG
Middle Name:
Last Name:LIUO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 FIELD
Mailing Address - Street 2:#650
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3345
Mailing Address - Country:US
Mailing Address - Phone:949-981-4515
Mailing Address - Fax:
Practice Address - Street 1:1200 N MAIN ST
Practice Address - Street 2:#650
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3640
Practice Address - Country:US
Practice Address - Phone:714-824-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001948363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health