Provider Demographics
NPI:1841587789
Name:CLARY, JUDITH RYAN (PA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:RYAN
Last Name:CLARY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:MARIE
Other - Last Name:CODDINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2000 N BEAUREGARD ST
Mailing Address - Street 2:SUITE 330
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1748
Mailing Address - Country:US
Mailing Address - Phone:703-370-2400
Mailing Address - Fax:703-370-7214
Practice Address - Street 1:2000 N BEAUREGARD ST
Practice Address - Street 2:SUITE 330
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1748
Practice Address - Country:US
Practice Address - Phone:703-370-2400
Practice Address - Fax:703-370-7214
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006132363AM0700X
MDC0005383363AM0700X
VA0110005075363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112418CMedicaid
GA202I971425Medicare PIN
MDC0005383OtherMD MEDICAL LICENSE
GA202I971425Medicare PIN