Healthcare Provider Details

I. General information

NPI: 1518931591
Provider Name (Legal Business Name): VICTORIA MORIMOTO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N COMMERCE AVE
FRONT ROYAL VA
22630-2660
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD HAROLD SCHNITZER DIABETES, MAIL CODE OP05-DC
PORTLAND OR
97239-3098
US

V. Phone/Fax

Practice location:
  • Phone: 540-635-0800
  • Fax: 540-635-0801
Mailing address:
  • Phone: 503-494-1226
  • Fax: 503-494-4781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110008070
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008070
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: