Basic Information
| Provider Information | |||||||||
| NPI: | 1154440055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANESHVAR | ||||||||
| FirstName: | CAROLINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033965292 | ||||||||
| FaxNumber: | 7033965297 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SUNSET LN | ||||||||
| Address2: | |||||||||
| City: | CULPEPER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 227013917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033965292 | ||||||||
| FaxNumber: | 7033965297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601004886 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0110005118 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1154440055 | 05 | VA | MEDICAID |