Healthcare Provider Details

I. General information

NPI: 1427203595
Provider Name (Legal Business Name): ANDREW DOUGLAS ALLEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 SUNRISE VALLEY DR STE 500
RESTON VA
20191-5303
US

IV. Provider business mailing address

2901 TELESTAR CT. #300
FALLS CHURCH VA
22042-1261
US

V. Phone/Fax

Practice location:
  • Phone: 703-437-5977
  • Fax: 703-478-2475
Mailing address:
  • Phone: 703-591-1688
  • Fax: 703-591-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003832
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: