Provider Demographics
NPI:1205886405
Name:MOGADAM, EVELYN C (NP)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:C
Last Name:MOGADAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 ANN FITZHUGH DR.
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003
Mailing Address - Country:US
Mailing Address - Phone:703-796-3075
Mailing Address - Fax:
Practice Address - Street 1:2901 TELESTAR CT STE 200
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1262
Practice Address - Country:US
Practice Address - Phone:703-573-3494
Practice Address - Fax:703-573-5353
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001077801363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP01244135OtherRAILROAD MEDICARE
VA1205886405Medicaid
VAS82375Medicare UPIN
VA1205886405Medicaid