Basic Information
| Provider Information | |||||||||
| NPI: | 1093882532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NILES | ||||||||
| FirstName: | LATOYA | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORDON | ||||||||
| OtherFirstName: | LATOYA | ||||||||
| OtherMiddleName: | BRENEKA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 237 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154313640 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2511 OLD CORNWALLIS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277131869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199325700 | ||||||||
| FaxNumber: | 9199336881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3667 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-06340 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.