1831625441 NPI number — TAMARA LIASCHENKO MA LCASA

Table of content: BLAIR DIETERLEN (NPI 1710853825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831625441 NPI number — TAMARA LIASCHENKO MA LCASA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIASCHENKO
Provider First Name:
TAMARA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA LCASA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831625441
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5605
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMERALD ISLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28594-5605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-515-0557
Provider Business Mailing Address Fax Number:
252-503-7399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7901 EMERALD DR
Provider Second Line Business Practice Location Address:
SUITE 15
Provider Business Practice Location Address City Name:
EMERALD ISLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28594-2846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-515-0557
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LCAS-23381 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)