Provider Demographics
NPI:1356103303
Name:EGUCHI, SHAE (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHAE
Middle Name:
Last Name:EGUCHI
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151071
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-1071
Mailing Address - Country:US
Mailing Address - Phone:703-540-0068
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 151071
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-1071
Practice Address - Country:US
Practice Address - Phone:703-540-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-06-12
Deactivation Date:2024-03-16
Deactivation Code:
Reactivation Date:2024-06-12
Provider Licenses
StateLicense IDTaxonomies
VA0024189189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily