Basic Information
| Provider Information | |||||||||
| NPI: | 1114967429 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NASRALLAH | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | NASH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2025 FRONTIS PLAZA BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443199 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 W 8TH ST | ||||||||
| Address2: | UFJAX - DEPT. OF MEDICINE (GI) | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046330797 | ||||||||
| FaxNumber: | 9046330028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 101643 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003143088A | 05 | GA | MEDICAID | 010295600 | 05 | FL | MEDICAID |