Healthcare Provider Details

I. General information

NPI: 1063749141
Provider Name (Legal Business Name): MEGAN R SLOCUM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN R ODEN P.A.

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4724
  • Fax: 571-472-0241
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008200
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number085003616
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031506
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: