Provider Demographics
NPI:1134507734
Name:JIVIDEN, ERIC (MPAS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:JIVIDEN
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13700 CRYSTALFORD CT
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-2085
Mailing Address - Country:US
Mailing Address - Phone:703-969-4190
Mailing Address - Fax:
Practice Address - Street 1:13700 CRYSTALFORD CT
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-2085
Practice Address - Country:US
Practice Address - Phone:703-969-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002105363AM0700X
NC103779363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical