Provider Demographics
NPI:1598077448
Name:AUSTIN, LA TANYA (MD)
Entity Type:Individual
Prefix:DR
First Name:LA TANYA
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 24TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT GREGG ADAMS
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-6093
Mailing Address - Fax:804-734-6263
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT GREGG ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-6093
Practice Address - Fax:804-734-6263
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA125.058885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine