Provider Demographics
NPI:1063816155
Name:NOVA WOUND CARE, P.C.
Entity Type:Organization
Organization Name:NOVA WOUND CARE, P.C.
Other - Org Name:TKR GROUP, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAPHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-876-2710
Mailing Address - Street 1:115 BEULAH RD NE
Mailing Address - Street 2:100D
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4749
Mailing Address - Country:US
Mailing Address - Phone:703-652-4251
Mailing Address - Fax:703-652-8470
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:303
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-664-8025
Practice Address - Fax:703-652-8470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255673943Medicaid