Provider Demographics
NPI:1568667897
Name:KANIANTHRA, ELIZABETH B (PAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:B
Last Name:KANIANTHRA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8640 SUDLEY ROAD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4404
Mailing Address - Country:US
Mailing Address - Phone:703-361-7778
Mailing Address - Fax:703-392-6231
Practice Address - Street 1:8640 SUDLEY ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4404
Practice Address - Country:US
Practice Address - Phone:703-361-7778
Practice Address - Fax:703-392-6231
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110840327363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant