Healthcare Provider Details

I. General information

NPI: 1427513803
Provider Name (Legal Business Name): NICHOLAS JORGE CORDOVA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2019
Last Update Date: 12/13/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 AMHERST ST
WINCHESTER VA
22601-2808
US

IV. Provider business mailing address

109 TEAL WAY
WILLIAMSBURG VA
23188-1675
US

V. Phone/Fax

Practice location:
  • Phone: 540-536-8700
  • Fax: 540-536-7800
Mailing address:
  • Phone: 757-565-0794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007079
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: