1497945174 NPI number — MIRIAM JACQUELINE NICOLASA CUSICANQUI MONRROY MD

Table of content: MIRIAM JACQUELINE NICOLASA CUSICANQUI MONRROY MD (NPI 1497945174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497945174 NPI number — MIRIAM JACQUELINE NICOLASA CUSICANQUI MONRROY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUSICANQUI MONRROY
Provider First Name:
MIRIAM
Provider Middle Name:
JACQUELINE NICOLASA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDICINE
Provider Other First Name:
BALLSTON
Provider Other Middle Name:
FAMILY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1497945174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4710 OLD DOMINION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22207-3527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-527-4466
Provider Business Mailing Address Fax Number:
703-552-1326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1715 N GEORGE MASON DR
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22205-3609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-527-4466
Provider Business Practice Location Address Fax Number:
703-552-1326
Provider Enumeration Date:
07/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101241806 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 132601 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7100033620 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1497945174 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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