Provider Demographics
NPI:1174758908
Name:PHU, LIZA ANTOINETTE JAIN (MD)
Entity type:Individual
Prefix:DR
First Name:LIZA ANTOINETTE
Middle Name:JAIN
Last Name:PHU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIZA ANTOINETTE
Other - Middle Name:GARCIA
Other - Last Name:JAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:265 CREEK LN S
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1214
Practice Address - Country:US
Practice Address - Phone:952-428-1200
Practice Address - Fax:952-428-1201
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60116222207Q00000X
IL036.129032207Q00000X
MN53359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG33980Medicare UPIN