Healthcare Provider Details

I. General information

NPI: 1245833979
Provider Name (Legal Business Name): KATIE YOON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2883 STAR OPAL DR
FAIRFAX VA
22031-1354
US

IV. Provider business mailing address

2883 STAR OPAL DR
FAIRFAX VA
22031-1354
US

V. Phone/Fax

Practice location:
  • Phone: 571-331-1821
  • Fax:
Mailing address:
  • Phone: 57-159-4405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025967
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: