Basic Information
| Provider Information | |||||||||
| NPI: | 1376581645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | ANUSHAYA | ||||||||
| MiddleName: | MISRA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MISRA | ||||||||
| OtherFirstName: | ANOO | ||||||||
| OtherMiddleName: | SHAYA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 17334 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212971334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034436717 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 224D CORNWALL ST NW | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037773262 | ||||||||
| FaxNumber: | 7037773365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110001287 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 008955301 | 05 | VA | MEDICAID |