Healthcare Provider Details

I. General information

NPI: 1811185481
Provider Name (Legal Business Name): PREMIERE CENTER FOR COSMETIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 PENDER DR SUITE 120
FAIRFAX VA
22030-0985
US

IV. Provider business mailing address

2419 W KENNEDY BLVD STE 101
TAMPA FL
33609-3481
US

V. Phone/Fax

Practice location:
  • Phone: 703-752-6608
  • Fax:
Mailing address:
  • Phone: 813-400-1465
  • Fax: 813-386-0513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA TRAUTMAN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 813-305-9100