Provider Demographics
NPI:1003925108
Name:SUTHERLAND, IDA E (FNP-BC)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:E
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-2428
Mailing Address - Country:US
Mailing Address - Phone:540-639-5300
Mailing Address - Fax:540-639-4653
Practice Address - Street 1:600 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2428
Practice Address - Country:US
Practice Address - Phone:540-639-5300
Practice Address - Fax:540-639-4653
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003925108OtherVA PREMIER
VA1003925108Medicaid
VA1003925108Medicaid
VA1003925108OtherVA PREMIER