Healthcare Provider Details

I. General information

NPI: 1881321891
Provider Name (Legal Business Name): WONDIMU S YIRGA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 TWIN HICKORY RD
GLEN ALLEN VA
23059-5682
US

IV. Provider business mailing address

5310 TWIN HICKORY RD
GLEN ALLEN VA
23059-5682
US

V. Phone/Fax

Practice location:
  • Phone: 804-603-1490
  • Fax: 320-238-8026
Mailing address:
  • Phone: 804-441-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024187876
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024187876
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024187876
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: