Provider Demographics
NPI:1407295215
Name:BANSAL, DIVYA (PA-C)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:BANSAL
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 1:224-D CORNWALL STREET NW, SUITE 204
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-372-2024
Practice Address - Street 1:8988 LORTON STATION BLVD, SUITE 202
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4758
Practice Address - Country:US
Practice Address - Phone:703-372-2280
Practice Address - Fax:703-372-2024
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031036363A00000X
VA0110-004272363AS0400X
VA0110004272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30016833620001Medicaid
VA1407295215Medicaid