Healthcare Provider Details

I. General information

NPI: 1407447931
Provider Name (Legal Business Name): DRISTI BASNET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4379 RIDGEWOOD CENTER DR STE 102
WOODBRIDGE VA
22192-8323
US

IV. Provider business mailing address

11901 WASHINGTON ST
FAIRFAX VA
22030-5740
US

V. Phone/Fax

Practice location:
  • Phone: 571-331-8086
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0024179963
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: