Provider Demographics
NPI:1619357308
Name:MADAN, PRACHI
Entity Type:Individual
Prefix:
First Name:PRACHI
Middle Name:
Last Name:MADAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 810
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-823-0333
Mailing Address - Fax:703-823-8611
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 810
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-823-0333
Practice Address - Fax:703-823-8611
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004949363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical