MEDICARE: ALAZAR KASSA FEDLU

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
1	363A00000X	Physician Assistant	0110009519	VA

General Provider Information

NPI Number	:	1508631011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALAZAR KASSA FEDLU

Provider Business Mailing Address
First Line	:	2260 STONE WHEEL DR APT E
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20191-3126
Country	:	US
Telephone Number	:	571-478-7770
Fax Number	:

Provider Business Practice Location Address
First Line	:	2260 STONE WHEEL DR APT E
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20191-3126
Country	:	US
Telephone Number	:	571-478-7770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2023
Last Update Date	:	11/15/2023

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