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General NPI Number Information
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NPI Number | 1902973423
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Entity Type | Organization
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Legal Business Name | CENTER FOR PRIMARY CARE & GERIATRICS
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 05/28/2023
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Provider Practice Location Address
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Address Line | 7115 LEESBURG PIKE STE 211
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City | FALLS CHURCH
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State | VA
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Zip | 22043-2301
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Country | US
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Telephone | 703-532-1111
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Fax | 703-532-3224
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Provider Business Mailing Address
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Address Line | 6319 CASTLE PLACE SUITE #3D
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City | FALLS CHURCH
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State | VA
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Zip | 22044-1907
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Country | US
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Telephone | 703-532-1111
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Fax | 703-532-3224
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | DR. CISSY PAUL POTTANAT
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Credential | MD MPH
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Telephone | 703-532-9411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101056325
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License Number State | VA
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