Provider Demographics
NPI:1083062392
Name:RACADAG, IVAN (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:RACADAG
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 SPRING HILL RD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-7510
Mailing Address - Country:US
Mailing Address - Phone:571-599-5643
Mailing Address - Fax:703-270-4350
Practice Address - Street 1:1604 SPRING HILL RD
Practice Address - Street 2:SUITE 450
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-7510
Practice Address - Country:US
Practice Address - Phone:571-599-5643
Practice Address - Fax:703-270-4350
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173957363LA2200X
VA0001230039163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse