Basic Information
| Provider Information | |||||||||
| NPI: | 1093922197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAZLI | ||||||||
| FirstName: | AYESHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3716 MELROSE AVE NW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240172716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403620360 | ||||||||
| FaxNumber: | 5403625590 | ||||||||
| Practice Location | |||||||||
| Address1: | 3716 MELROSE AVE NW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240172716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403620360 | ||||||||
| FaxNumber: | 5403625590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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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 | 207Q00000X | 22742 | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101239912 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810009211 | 05 | WV | MEDICAID | 000056944U | 01 | WV | HUMANA | OTHER | 001969694 | 01 | WV | MOUNTAIN STATE BLUE CROSS | OTHER | P00401503 | 01 | WV | RAILROAD MEDICARE PIN | OTHER |