Provider Demographics
NPI:1194363523
Name:WIXSON, FREDERIC (MSPT, GCS)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:
Last Name:WIXSON
Suffix:
Gender:M
Credentials:MSPT, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 E WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-1227
Mailing Address - Country:US
Mailing Address - Phone:703-739-8244
Mailing Address - Fax:
Practice Address - Street 1:417 E WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-1227
Practice Address - Country:US
Practice Address - Phone:703-739-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005410261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000000OtherNONE