Healthcare Provider Details

I. General information

NPI: 1376939017
Provider Name (Legal Business Name): EMILY SHEA KOWALSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

8081 INNOVATION PARK DR
FAIRFAX VA
22031-4867
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-0540
  • Fax:
Mailing address:
  • Phone: 571-472-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberD90039
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: