Basic Information
| Provider Information | |||||||||
| NPI: | 1548545296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMONETTI | ||||||||
| FirstName: | BLAIR | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SNYDER | ||||||||
| OtherFirstName: | BLAIR | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11800 SUNRISE VALLEY DR STE 800 | ||||||||
| Address2: | |||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201915320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037091114 | ||||||||
| FaxNumber: | 7037091117 | ||||||||
| Practice Location | |||||||||
| Address1: | 1831 WIEHLE AVE | ||||||||
| Address2: | |||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037091114 | ||||||||
| FaxNumber: | 7037091117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2011 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110003695 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.