Provider Demographics
NPI:1336747963
Name:LILES, THOMAS (NP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LILES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CWCU
Mailing Address - Street 2:4 CARLSON CT
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119
Mailing Address - Country:US
Mailing Address - Phone:202-532-3778
Mailing Address - Fax:
Practice Address - Street 1:4 CARLSON CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-5901
Practice Address - Country:US
Practice Address - Phone:202-532-3778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137858363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily