Healthcare Provider Details

I. General information

NPI: 1942599634
Provider Name (Legal Business Name): TREVOR MICHIO UYEMURA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11211 WAPLES MILL RD STE 200
FAIRFAX VA
22030-7406
US

IV. Provider business mailing address

11211 WAPLES MILL RD SUITE 200
FAIRFAX VA
22030-7406
US

V. Phone/Fax

Practice location:
  • Phone: 703-246-9560
  • Fax: 703-246-9564
Mailing address:
  • Phone: 703-246-9560
  • Fax: 703-246-9564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0101259708
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: