Provider Demographics
NPI:1043742208
Name:TALLMAN, NICHOLAS RAYMOND
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RAYMOND
Last Name:TALLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:490 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1769
Practice Address - Country:US
Practice Address - Phone:540-484-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00777208000000X
VA0102208387208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics