Provider Demographics
NPI:1508631011
Name:FEDLU, ALAZAR KASSA
Entity Type:Individual
Prefix:
First Name:ALAZAR
Middle Name:KASSA
Last Name:FEDLU
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 1:2260 STONE WHEEL DR APT E
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-3126
Mailing Address - Country:US
Mailing Address - Phone:571-478-7770
Mailing Address - Fax:
Practice Address - Street 1:2260 STONE WHEEL DR APT E
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3126
Practice Address - Country:US
Practice Address - Phone:571-478-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant