Healthcare Provider Details

I. General information

NPI: 1376306456
Provider Name (Legal Business Name): DONALD TYLER PUBINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13350 FRANKLIN FARM RD
HERNDON VA
20171-4091
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 703-810-5204
  • Fax:
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305216270
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: