Healthcare Provider Details

I. General information

NPI: 1205165016
Provider Name (Legal Business Name): ARLENE KELLER SUROS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N GEORGE MASON DR SUITE 425
ARLINGTON VA
22205-3683
US

IV. Provider business mailing address

1625 N GEORGE MASON DR SUITE 425
ARLINGTON VA
22205-3683
US

V. Phone/Fax

Practice location:
  • Phone: 703-717-4400
  • Fax: 703-717-4401
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003174
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA030638
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0004120
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: