Healthcare Provider Details

I. General information

NPI: 1720111016
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF MANASSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 DIGGES RD SUITE 107
MANASSAS VA
20110-4421
US

IV. Provider business mailing address

9001 DIGGES RD SUITE 107
MANASSAS VA
20110-4421
US

V. Phone/Fax

Practice location:
  • Phone: 703-368-9131
  • Fax: 703-368-2038
Mailing address:
  • Phone: 703-368-9131
  • Fax: 703-368-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ADONIA JOHNSON
Title or Position: BILLING
Credential:
Phone: 703-368-9131