Basic Information
| Provider Information | |||||||||
| NPI: | 1750352738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOBU | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12011 LEE JACKSON MEMORIAL HIGHWAY | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912030 | ||||||||
| FaxNumber: | 7032733943 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 JOSEPH SIEWICK DRIVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912020 | ||||||||
| FaxNumber: | 7033911211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 10/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101041159 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5640679 | 05 | VA | MEDICAID |