Provider Demographics
NPI:1093882532
Name:NILES, LATOYA GORDON (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LATOYA
Middle Name:GORDON
Last Name:NILES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:LATOYA
Other - Middle Name:BRENEKA
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:237 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2549
Mailing Address - Country:US
Mailing Address - Phone:615-431-3640
Mailing Address - Fax:
Practice Address - Street 1:2511 OLD CORNWALLIS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1869
Practice Address - Country:US
Practice Address - Phone:919-932-5700
Practice Address - Fax:919-933-6881
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3667363A00000X
NC0010-06340363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant