Healthcare Provider Details

I. General information

NPI: 1316002751
Provider Name (Legal Business Name): JOHN W. WIRES PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 PENDER DR SUITE 320
FAIRFAX VA
22030-6041
US

IV. Provider business mailing address

3959 PENDER DR SUITE 320
FAIRFAX VA
22030-6041
US

V. Phone/Fax

Practice location:
  • Phone: 703-352-3822
  • Fax: 703-385-8353
Mailing address:
  • Phone: 703-352-3822
  • Fax: 703-385-8353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1681
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: