Healthcare Provider Details

I. General information

NPI: 1992094494
Provider Name (Legal Business Name): NOVA PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR SUITE 255
RESTON VA
20190-5896
US

IV. Provider business mailing address

1860 TOWN CENTER DR SUITE 255
RESTON VA
20190-5896
US

V. Phone/Fax

Practice location:
  • Phone: 703-574-2588
  • Fax: 703-574-3648
Mailing address:
  • Phone: 703-574-2588
  • Fax: 703-574-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101248274
License Number StateVA

VIII. Authorized Official

Name: DR. FADI NUKTA
Title or Position: MANAGING MEMBER
Credential: M.D
Phone: 703-574-2588