Healthcare Provider Details

I. General information

NPI: 1093327983
Provider Name (Legal Business Name): MARIAH CLUSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 AMHERST ST
WINCHESTER VA
22601-2864
US

IV. Provider business mailing address

1867 AMHERST ST
WINCHESTER VA
22601-2864
US

V. Phone/Fax

Practice location:
  • Phone: 540-667-8724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008714
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: