Provider Demographics
NPI:1417301607
Name:ESPINO, JOSE GUSTAVO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:GUSTAVO
Last Name:ESPINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6866 DEER RUN DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-1124
Mailing Address - Country:US
Mailing Address - Phone:703-307-8999
Mailing Address - Fax:
Practice Address - Street 1:6866 DEER RUN DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-1124
Practice Address - Country:US
Practice Address - Phone:703-307-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD363AS0400X
DCSA0191246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical