Provider Demographics
NPI:1639714934
Name:IDUMA, MICHAEL (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:IDUMA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9420 PARK HUNT CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-1351
Mailing Address - Country:US
Mailing Address - Phone:703-909-4803
Mailing Address - Fax:
Practice Address - Street 1:9420 PARK HUNT CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-1351
Practice Address - Country:US
Practice Address - Phone:703-909-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-10
Last Update Date:2019-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily