Provider Demographics
NPI:1770671919
Name:VIDWANS, KRISTIN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:VIDWANS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 HUTCHISON GROVE CT
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-2556
Mailing Address - Country:US
Mailing Address - Phone:703-863-4270
Mailing Address - Fax:703-914-2536
Practice Address - Street 1:6715 LITTLE RIVER TPKE
Practice Address - Street 2:201
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3546
Practice Address - Country:US
Practice Address - Phone:703-914-3640
Practice Address - Fax:703-914-2536
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002272363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110002272OtherLICENSE