Basic Information
| Provider Information | |||||||||
| NPI: | 1104883115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NANNA | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N SHENANDOAH AVE | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226303547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406360300 | ||||||||
| FaxNumber: | 5406360198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 N SHENANDOAH AVE | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226303547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406360300 | ||||||||
| FaxNumber: | 5406360198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101042798 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930089866 | 01 | VA | MEDICARE RAILROAD | OTHER | 005836891 | 05 | VA | MEDICAID |