Provider Demographics
NPI:1104044924
Name:WOTKA, MEREDITH H (PA)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:H
Last Name:WOTKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 N GEORGE MASON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3601
Mailing Address - Country:US
Mailing Address - Phone:035-241-2127
Mailing Address - Fax:
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3601
Practice Address - Country:US
Practice Address - Phone:703-524-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1260363A00000X
VA0110006784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA6026OtherSTATE PHYSICIAN ASSISTANT LICENSE
NE1260OtherSTATE LICENSE NUMBER
AZ6628OtherSTATE PHYSICIAN ASSISTANT LICENSE
CAPA54114OtherSTATE PHYSICIAN ASSISTANT LICENSE
NY020484-1OtherSTATE PHYSICIAN ASSISTANT LICENSE
IL085.0006096OtherSTATE PHYSICIAN ASSISTANT LICENSE
DCPA031320OtherSTATE PHYSICIAN ASSISTANT LICENSE