Provider Demographics
NPI:1497945174
Name:CUSICANQUI MONRROY, MIRIAM JACQUELINE NICOLASA (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:JACQUELINE NICOLASA
Last Name:CUSICANQUI MONRROY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BALLSTON
Other - Middle Name:FAMILY
Other - Last Name:MEDICINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4710 OLD DOMINION DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-3527
Mailing Address - Country:US
Mailing Address - Phone:703-527-4466
Mailing Address - Fax:703-552-1326
Practice Address - Street 1:1715 N GEORGE MASON DR
Practice Address - Street 2:SUITE 501
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3609
Practice Address - Country:US
Practice Address - Phone:703-527-4466
Practice Address - Fax:703-552-1326
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-28
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA132601OtherMEDICARE PTAN
KY7100033620Medicaid
VA1497945174Medicaid
VA132601OtherMEDICARE PTAN
VA016869W82Medicare PIN