Provider Demographics
NPI:1831299445
Name:GOTTLIEB, LIANA B (PA)
Entity Type:Individual
Prefix:
First Name:LIANA
Middle Name:B
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1806 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4014
Mailing Address - Country:US
Mailing Address - Phone:336-768-3632
Mailing Address - Fax:336-768-4473
Practice Address - Street 1:1806 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4014
Practice Address - Country:US
Practice Address - Phone:336-768-3632
Practice Address - Fax:336-768-4473
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC100625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant