Healthcare Provider Details

I. General information

NPI: 1558242412
Provider Name (Legal Business Name): JAWUANTAE RIDGEWAY CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 10/24/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 PARKERS LN
ALEXANDRIA VA
22306-3209
US

IV. Provider business mailing address

2501 PARKERS LN
ALEXANDRIA VA
22306-3209
US

V. Phone/Fax

Practice location:
  • Phone: 931-302-0971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000871
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: