Healthcare Provider Details

I. General information

NPI: 1023624905
Provider Name (Legal Business Name): MELISSA HAUG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR STE 300
WOODBRIDGE VA
22191-3337
US

IV. Provider business mailing address

14605 POTOMAC BRANCH DR STE 300
WOODBRIDGE VA
22191-3337
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110007428
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007428
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: