Healthcare Provider Details

I. General information

NPI: 1023069531
Provider Name (Legal Business Name): MR. WILLIAM RUSSELL BARTOW JR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/19/2012
Certification Date:
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: 703-664-7218
  • Fax: 703-664-7317
Mailing address:
  • Phone: 703-664-7218
  • Fax: 703-664-7317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110000104
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: