Healthcare Provider Details

I. General information

NPI: 1760633283
Provider Name (Legal Business Name): XYZ CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 BREEZE LANE
FAIRFAX VA
22033
US

IV. Provider business mailing address

17000 BREEZE LANE
FAIRFAX VA
22033
US

V. Phone/Fax

Practice location:
  • Phone: 703-777-2222
  • Fax:
Mailing address:
  • Phone: 703-777-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number908832094382904
License Number StateVA

VIII. Authorized Official

Name: JIM SMITH
Title or Position: ADMINISTRATOR
Credential:
Phone: 703-777-2222