Provider Demographics
NPI:1811417264
Name:TAILLAC, VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:TAILLAC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N OAK ST APT 1402
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22209-2613
Mailing Address - Country:US
Mailing Address - Phone:801-699-8403
Mailing Address - Fax:
Practice Address - Street 1:3301 WILSON BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-2228
Practice Address - Country:US
Practice Address - Phone:703-522-1860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
DCPA031370363A00000X
VA0110005954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant