Healthcare Provider Details

I. General information

NPI: 1710594635
Provider Name (Legal Business Name): PAUL JOSEPH BEDNARSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7661 PROVINCIAL DR APT 302
MC LEAN VA
22102-7662
US

IV. Provider business mailing address

7661 PROVINCIAL DR APT 302
MC LEAN VA
22102-7662
US

V. Phone/Fax

Practice location:
  • Phone: 703-338-2505
  • Fax:
Mailing address:
  • Phone: 703-338-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019016815
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: