Healthcare Provider Details

I. General information

NPI: 1043900822
Provider Name (Legal Business Name): AYSHA DADA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10575 NORTHFAX ST
FAIRFAX VA
22030
US

IV. Provider business mailing address

10575 NORTHFAX ST
FAIRFAX VA
22030
US

V. Phone/Fax

Practice location:
  • Phone: 740-762-4148
  • Fax:
Mailing address:
  • Phone: 740-762-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110011778
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: