Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 036115999 | IL |
N | 208600000X | Surgeon | 036115999 | IL |
Y | 2086S0127X | Trauma Surgeon | 036115999 | IL |
NPI | 1386747731 |
---|---|
Provider Name | Dr. Daniel A Liesen |
First Address | Gurnee, IL 60031-5711 |
Second Address | Gurnee, IL 60031-5711 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2006 |
Last Update Date | 16/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036115999 | (05) | IL |
036115999 | LICENSE (01) | IL |