Healthcare Provider Details

I. General information

NPI: 1255372074
Provider Name (Legal Business Name): SUSAN G HOLBERGER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 TOWN CENTER PARKWAY RESTON HOSPITAL CENTER
RESTON VA
20190
US

IV. Provider business mailing address

1300 PICCARD DR STE 202
ROCKVILLE MD
20850-4303
US

V. Phone/Fax

Practice location:
  • Phone: 703-689-9037
  • Fax: 703-689-9109
Mailing address:
  • Phone: 301-921-7900
  • Fax: 301-921-7915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110840530
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: