Healthcare Provider Details

I. General information

NPI: 1649548801
Provider Name (Legal Business Name): NADIA PERITSALIS HERRERA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 01/13/2021
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6849 OLD DOMINION DR STE 450
MC LEAN VA
22101-3718
US

IV. Provider business mailing address

604 H ST SW
WASHINGTON DC
20024-2728
US

V. Phone/Fax

Practice location:
  • Phone: 703-356-5111
  • Fax:
Mailing address:
  • Phone: 251-610-4139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberAMD-585
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-007100
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: