Provider Demographics
NPI:1275108607
Name:VITEZ, MICHAELA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:LYNN
Last Name:VITEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21772 SLATE RANGE TER UNIT 102
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-7801
Mailing Address - Country:US
Mailing Address - Phone:301-616-7901
Mailing Address - Fax:
Practice Address - Street 1:7432 LITTLE RIVER TPKE
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3013
Practice Address - Country:US
Practice Address - Phone:703-658-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110007940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant