Basic Information
| Provider Information | |||||||||
| NPI: | 1932127644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ANGELIQUE | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11240 WAPLES MILL ROAD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032468080 | ||||||||
| FaxNumber: | 7036914932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 TOWN CENTER PARKWAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036890300 | ||||||||
| FaxNumber: | 7037879664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0110002122 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.