Healthcare Provider Details

I. General information

NPI: 1518259431
Provider Name (Legal Business Name): SASA-GRAE M ESPINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 02/10/2022
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MEDICAL PARK BLVD STE 275
PETERSBURG VA
23805-9348
US

IV. Provider business mailing address

8580 MAGELLAN PKWY
RICHMOND VA
23227-1149
US

V. Phone/Fax

Practice location:
  • Phone: 804-765-5905
  • Fax: 804-765-5925
Mailing address:
  • Phone: 804-520-6730
  • Fax: 804-520-6731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number101262899
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number101262899
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: