Healthcare Provider Details

I. General information

NPI: 1932826922
Provider Name (Legal Business Name): ALISA KUZNETSOVA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11161 NEW HAMPSHIRE AVE STE 102
SILVER SPRING MD
20904-2606
US

IV. Provider business mailing address

11161 NEW HAMPSHIRE AVE STE 102
SILVER SPRING MD
20904-2606
US

V. Phone/Fax

Practice location:
  • Phone: 301-434-0599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0008678
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: