Healthcare Provider Details

I. General information

NPI: 1689070872
Provider Name (Legal Business Name): MR. STEVE GWALTNEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N GEORGE MASON DR
ARLINGTON VA
22205-3610
US

IV. Provider business mailing address

2401 HAY RAKE CT
HERNDON VA
20171-4328
US

V. Phone/Fax

Practice location:
  • Phone: 703-558-6173
  • Fax:
Mailing address:
  • Phone: 757-537-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0001207237
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: