Provider Demographics
NPI:1669499091
Name:RUPP, PAUL G (ATC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:G
Last Name:RUPP
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11044 GRANBY CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-5021
Mailing Address - Country:US
Mailing Address - Phone:703-716-5778
Mailing Address - Fax:
Practice Address - Street 1:2900 SUTTON RD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22181-6109
Practice Address - Country:US
Practice Address - Phone:703-319-2833
Practice Address - Fax:703-319-2713
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260001512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer