Provider Demographics
NPI:1629100185
Name:HANLEY-NIEMAN, MOIRA (PA-C)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:HANLEY-NIEMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:211 GIBSON STREET, NW, SUITE 215
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2115
Practice Address - Country:US
Practice Address - Phone:571-707-2085
Practice Address - Fax:571-291-9196
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003807363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629100185Medicaid
VA30015872740001Medicaid