Basic Information
| Provider Information | |||||||||
| NPI: | 1528253846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HILTON | ||||||||
| FirstName: | LATISHA | ||||||||
| MiddleName: | MECHELE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOWMAN | ||||||||
| OtherFirstName: | LATISHA | ||||||||
| OtherMiddleName: | MECHELE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 716 SPRING ST. | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | WISE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763288910 | ||||||||
| FaxNumber: | 2763284318 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 SPRING STREET | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | WISE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763298910 | ||||||||
| FaxNumber: | 2763284318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0102202078 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00819102 | 01 | RR MEDICARE | OTHER | 1528253846 | 05 | VA | MEDICAID | 7100077100 | 05 | KY | MEDICAID | C10456 | 01 | VA | TRAILBLAZER | OTHER |