Provider Demographics
NPI:1114426392
Name:MURUGANANDAM, DIVIYALAXMI (PA)
Entity Type:Individual
Prefix:MRS
First Name:DIVIYALAXMI
Middle Name:
Last Name:MURUGANANDAM
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 1:1521 BOYD POINTE WAY APT 2710
Mailing Address - Street 2:
Mailing Address - City:TYSONS
Mailing Address - State:VA
Mailing Address - Zip Code:22182-7561
Mailing Address - Country:US
Mailing Address - Phone:703-981-5533
Mailing Address - Fax:
Practice Address - Street 1:381 ELDEN ST STE 1000
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4842
Practice Address - Country:US
Practice Address - Phone:703-481-1505
Practice Address - Fax:703-742-8793
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006077207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110006077OtherLICENSE