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NPI Code Detail

MEDICARE: IAN JACOB HENRY

MEDICARE: IAN JACOB HENRY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant
2363AM0700XMedical Physician Assistant

General Provider Information

NPI Number : 1043971047
Entity Type Code : Individual
Provider Name (Legal Business Name) : IAN JACOB HENRY
Provider Business Mailing Address
First Line : 127 FORT EVANS RD SE APT A
Second Line :
City : LEESBURG
State : VA
Zip : 20175-4142
Country : US
Telephone Number : 703-371-4437
Fax Number :
Provider Business Practice Location Address
First Line : 1850 TOWN CENTER PKWY
Second Line :
City : RESTON
State : VA
Zip : 20190-3298
Country : US
Telephone Number : 703-689-9000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/03/2022
Last Update Date : 06/24/2022

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