Healthcare Provider Details

I. General information

NPI: 1053119818
Provider Name (Legal Business Name): ELITE PRIMARY CARE AND AESTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 BREEZEPORT WAY STE 300
SUFFOLK VA
23435-3736
US

IV. Provider business mailing address

523 CARTER CT
NEWPORT NEWS VA
23603-1073
US

V. Phone/Fax

Practice location:
  • Phone: 332-330-3903
  • Fax:
Mailing address:
  • Phone: 332-330-3903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ASIA GORDON
Title or Position: OWNER
Credential:
Phone: 332-330-3903