Healthcare Provider Details

I. General information

NPI: 1609252279
Provider Name (Legal Business Name): ANN ELIZABETH MARCACCINI PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E PARHAM RD
RICHMOND VA
23228-3118
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 804-264-7808
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax: 804-217-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006149
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: