Basic Information
| Provider Information | |||||||||
| NPI: | 1437740982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWENTER | ||||||||
| FirstName: | SOO MIN | ||||||||
| MiddleName: | SUMMER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2807 S WOODROW ST APT B | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222063321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712750704 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037764001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2021 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001274958 | VA | N | Nursing Service Providers | Registered Nurse | 367500000X | 0024180857 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.