Healthcare Provider Details

I. General information

NPI: 1558546242
Provider Name (Legal Business Name): ATOSSA E TAHVILDARY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2008
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 GEORGIA AVE NW WALTER REED ARMY MEDICAL CENTER ATN: MCHL-MAO-C
WASHINGTON DC
20307-0003
US

IV. Provider business mailing address

WRNMMC 8901 WISCONSIN AVE WALTER REED ARMY MEDICAL CENTER ATN: MCHL-MAO-C
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-7341
  • Fax:
Mailing address:
  • Phone: 301-295-7850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003442
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: