Healthcare Provider Details

I. General information

NPI: 1417301607
Provider Name (Legal Business Name): JOSE GUSTAVO ESPINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6866 DEER RUN DR
ALEXANDRIA VA
22306-1124
US

IV. Provider business mailing address

6866 DEER RUN DR
ALEXANDRIA VA
22306-1124
US

V. Phone/Fax

Practice location:
  • Phone: 703-307-8999
  • Fax:
Mailing address:
  • Phone: 703-307-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA0191
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: