Provider Demographics
NPI:1023179751
Name:PURVIS, MARIELLA (PAC)
Entity Type:Individual
Prefix:
First Name:MARIELLA
Middle Name:
Last Name:PURVIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 19TH ST NW
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036
Mailing Address - Country:US
Mailing Address - Phone:202-955-6995
Mailing Address - Fax:202-955-3915
Practice Address - Street 1:1120 19TH ST NW
Practice Address - Street 2:SUITE 250
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036
Practice Address - Country:US
Practice Address - Phone:202-955-6995
Practice Address - Fax:202-955-3915
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030302363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
012956U16Medicare ID - Type Unspecified
S74233Medicare UPIN