Provider Demographics
NPI:1336137587
Name:PECK, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:PECK
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 1:209 GIBSON ST NW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2122
Mailing Address - Country:US
Mailing Address - Phone:703-396-6197
Mailing Address - Fax:703-779-1372
Practice Address - Street 1:209 GIBSON ST NW
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2122
Practice Address - Country:US
Practice Address - Phone:703-396-6197
Practice Address - Fax:703-779-1372
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024088367363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S88763Medicare UPIN
DC000S73G65Medicare PIN