Healthcare Provider Details

I. General information

NPI: 1326436304
Provider Name (Legal Business Name): FAIRFAX FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2014
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 ELDEN ST
HERNDON VA
20170-4818
US

IV. Provider business mailing address

19182 CHARTIER DR
LEESBURG VA
20176-1622
US

V. Phone/Fax

Practice location:
  • Phone: 571-665-4000
  • Fax: 571-665-4003
Mailing address:
  • Phone: 703-507-7505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AHMAD NUSRAT
Title or Position: PRESIDENT
Credential:
Phone: 703-507-7505