Provider Demographics
NPI:1821511734
Name:TAHERI, MATINDOKHT (FNP)
Entity Type:Individual
Prefix:
First Name:MATINDOKHT
Middle Name:
Last Name:TAHERI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MATIN
Other - Middle Name:
Other - Last Name:CHANGIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1115 RIVA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-1616
Mailing Address - Country:US
Mailing Address - Phone:703-863-9500
Mailing Address - Fax:
Practice Address - Street 1:8008 WESTPARK DR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3109
Practice Address - Country:US
Practice Address - Phone:844-549-0597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine