Healthcare Provider Details

I. General information

NPI: 1730496415
Provider Name (Legal Business Name): HETTI THANTRIGE HIRUNI WATHSALA WICKRAMASINGHE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43480 YUKON DR
ASHBURN VA
20147-6988
US

IV. Provider business mailing address

43480 YUKON DR
ASHBURN VA
20147-6988
US

V. Phone/Fax

Practice location:
  • Phone: 571-252-6000
  • Fax:
Mailing address:
  • Phone: 571-252-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0075384
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: