Provider Demographics
NPI:1811959695
Name:LIACOS, DIANA M (PNP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:LIACOS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41A SYMPHONY RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-4004
Mailing Address - Country:US
Mailing Address - Phone:857-991-1076
Mailing Address - Fax:
Practice Address - Street 1:DOWLING 3 SOUTH, PEDIATRIC NEUROLOGY
Practice Address - Street 2:HARRISON AVE CAMPUS BOSTON MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-4569
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA161082363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics