Healthcare Provider Details

I. General information

NPI: 1205793502
Provider Name (Legal Business Name): MIA JO TAVERONI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 STAFFORD LAKES PKWY STE 102
FREDERICKSBURG VA
22406-7305
US

IV. Provider business mailing address

1340 CENTRAL PARK BLVD STE 100
FREDERICKSBURG VA
22401-4940
US

V. Phone/Fax

Practice location:
  • Phone: 540-741-6982
  • Fax:
Mailing address:
  • Phone: 540-741-6982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110011893
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: