=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407364268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PANTEHA NAZARI PT, DPT, BCB-PMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2018
-----------------------------------------------------
Last Update Date | 07/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 PROSPERITY AVE STE 260
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-291-3082
-----------------------------------------------------
Fax | 703-291-3083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 PROSPERITY AVE STE 260
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-291-3082
-----------------------------------------------------
Fax | 703-291-3083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 2305005082
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------