Healthcare Provider Details

I. General information

NPI: 1740850304
Provider Name (Legal Business Name): JONATHAN XAVIER KIEMEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 BRANDON AVE
SPRINGFIELD VA
22150-2610
US

IV. Provider business mailing address

6136 BRANDON AVE
SPRINGFIELD VA
22150-2610
US

V. Phone/Fax

Practice location:
  • Phone: 703-866-3131
  • Fax:
Mailing address:
  • Phone: 703-866-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008105
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: