Healthcare Provider Details

I. General information

NPI: 1184292963
Provider Name (Legal Business Name): OBGYNNOVA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6355 WALKER LN STE 408
ALEXANDRIA VA
22310-3250
US

IV. Provider business mailing address

6355 WALKER LN STE 408
ALEXANDRIA VA
22310-3250
US

V. Phone/Fax

Practice location:
  • Phone: 703-719-5901
  • Fax: 703-719-9628
Mailing address:
  • Phone: 703-719-5901
  • Fax: 703-719-9628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: TINA PHAM
Title or Position: PHYSICIAN
Credential: MD
Phone: 703-719-5901