Provider Demographics
NPI:1174296461
Name:JAH, PHANTA
Entity Type:Individual
Prefix:
First Name:PHANTA
Middle Name:
Last Name:JAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2833 CLEAVE DR.
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1837
Mailing Address - Country:US
Mailing Address - Phone:180-096-9110
Mailing Address - Fax:
Practice Address - Street 1:2833 CLEAVE DR.
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042
Practice Address - Country:US
Practice Address - Phone:800-969-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182355363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care