Provider Demographics
NPI:1104198001
Name:LEESBURG MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:LEESBURG MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NADYA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRIGER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:703-596-7000
Mailing Address - Street 1:44121 HARRY BYRD HWY STE 225
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5672
Mailing Address - Country:US
Mailing Address - Phone:703-596-7000
Mailing Address - Fax:800-609-0775
Practice Address - Street 1:44121 HARRY BYRD HWY STE 225
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5672
Practice Address - Country:US
Practice Address - Phone:703-596-7000
Practice Address - Fax:800-609-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169591261QP2300X
VA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1819974538OtherNPI