Provider Demographics
NPI:1639886138
Name:PATHAK, SMITA SANDEEP (NP)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:SANDEEP
Last Name:PATHAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:224 D CORNWALL STREET NW
Mailing Address - Street 2:STE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-773-8643
Practice Address - Street 1:44084 RIVERSIDE PARKWAY, SUITE 300
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5102
Practice Address - Country:US
Practice Address - Phone:703-724-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024185561363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1639886138Medicaid
VA30017626990001Medicaid