Provider Demographics
NPI:1407472574
Name:ROBERTSON, MIRIAM MAGDALENA (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:MAGDALENA
Last Name:ROBERTSON
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 1:2000 N BEAUREGARD ST UNIT 628
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-4645
Mailing Address - Country:US
Mailing Address - Phone:540-220-3594
Mailing Address - Fax:
Practice Address - Street 1:9001 DIGGES RD STE 105
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4414
Practice Address - Country:US
Practice Address - Phone:703-369-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110007354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant