Provider Demographics
NPI:1518774777
Name:LIU, JEREMY D (PA-C)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:D
Last Name:LIU
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 1:8104 SALADO SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-6923
Mailing Address - Country:US
Mailing Address - Phone:469-307-1139
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology