Provider Demographics
NPI:1720195175
Name:JEFFRIES, GARY (NP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:JEFFRIES
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:PO BOX 223323
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-3323
Mailing Address - Country:US
Mailing Address - Phone:540-349-0595
Mailing Address - Fax:540-349-0587
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3027
Practice Address - Country:US
Practice Address - Phone:540-349-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001091836363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007787936Medicaid
VA500000650Medicare PIN
VAG01425F06Medicare PIN
VAP00365961Medicare PIN
VA500015046Medicare PIN
VA007787936Medicaid