Provider Demographics
NPI:1033102157
Name:LASTOVA, PAUL LEWIS (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:LEWIS
Last Name:LASTOVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9860 LEE HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-1702
Mailing Address - Country:US
Mailing Address - Phone:703-383-1616
Mailing Address - Fax:703-383-1166
Practice Address - Street 1:9860 LEE HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-1702
Practice Address - Country:US
Practice Address - Phone:703-383-1616
Practice Address - Fax:703-383-1166
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist