Healthcare Provider Details

I. General information

NPI: 1518958545
Provider Name (Legal Business Name): RADER CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CARPENTER RD
FORT MYER VA
22211-1009
US

IV. Provider business mailing address

401 CARPENTER RD
FORT MYER VA
22211-1009
US

V. Phone/Fax

Practice location:
  • Phone: 703-696-3447
  • Fax:
Mailing address:
  • Phone: 703-696-3447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number495950
License Number StateCA

VIII. Authorized Official

Name: STACY EVA USHER
Title or Position: FAMILY NURSE PRACTITIONER
Credential: NP
Phone: 703-696-3447