Healthcare Provider Details

I. General information

NPI: 1174099808
Provider Name (Legal Business Name): MORIAH HANLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2018
Last Update Date: 07/10/2021
Certification Date: 07/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SAM PERRY BLVD STE 121
FREDERICKSBURG VA
22401-4465
US

IV. Provider business mailing address

2530 HARTFORD ST
SAN DIEGO CA
92110-2312
US

V. Phone/Fax

Practice location:
  • Phone: 540-899-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: