Provider Demographics
NPI:1164004776
Name:ROMAN, MITRO DARREN (STUDENT PTA)
Entity Type:Individual
Prefix:MR
First Name:MITRO
Middle Name:DARREN
Last Name:ROMAN
Suffix:
Gender:M
Credentials:STUDENT PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 FEDERAL CT
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-4428
Mailing Address - Country:US
Mailing Address - Phone:571-359-9730
Mailing Address - Fax:
Practice Address - Street 1:4040 FAIRFAX DR STE 120
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1613
Practice Address - Country:US
Practice Address - Phone:571-359-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty