Healthcare Provider Details

I. General information

NPI: 1376270801
Provider Name (Legal Business Name): LUTHER ACHU NJWEIPI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13088 BOURNE PL
BRISTOW VA
20136-1000
US

IV. Provider business mailing address

13088 BOURNE PL
BRISTOW VA
20136-1000
US

V. Phone/Fax

Practice location:
  • Phone: 571-361-8720
  • Fax:
Mailing address:
  • Phone: 571-361-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2022001257
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: