Provider Demographics
NPI:1346400520
Name:LISKE, ANGELA JOSETTA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:JOSETTA
Last Name:LISKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:JOSETTA
Other - Last Name:COPPOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:2018 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-5718
Practice Address - Country:US
Practice Address - Phone:865-544-0406
Practice Address - Fax:865-544-0480
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000033943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHG11198Medicare UPIN