Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 0102036988 | VA |
NPI | 1376750646 |
---|---|
Provider Name | Ms. Nancy Laura Liles |
First Address | Roanoke, VA 24019-3241 |
Second Address | Roanoke, VA 24019-3241 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
286206 | ANTHEM BCBS (01) | |
E27143 | (02) |