Healthcare Provider Details

I. General information

NPI: 1255596003
Provider Name (Legal Business Name): SEPIDEH SARRESHTEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47100 COMMUNITY PLZ
STERLING VA
20164-1826
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 703-880-1403
  • Fax:
Mailing address:
  • Phone: 804-822-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002761
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: