Healthcare Provider Details

I. General information

NPI: 1366047789
Provider Name (Legal Business Name): MANISHA KOCHHAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 PENDER DR STE 350
FAIRFAX VA
22030-0989
US

IV. Provider business mailing address

3930 PENDER DR STE 350
FAIRFAX VA
22030-0989
US

V. Phone/Fax

Practice location:
  • Phone: 703-865-8686
  • Fax:
Mailing address:
  • Phone: 703-865-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-007593
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: