Provider Demographics
NPI:1659503928
Name:PAVLOVA, MIROSLAVA
Entity type:Individual
Prefix:
First Name:MIROSLAVA
Middle Name:
Last Name:PAVLOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5631 BURKE CENTRE PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2234
Mailing Address - Country:US
Mailing Address - Phone:703-250-5171
Mailing Address - Fax:
Practice Address - Street 1:5631 BURKE CENTRE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2234
Practice Address - Country:US
Practice Address - Phone:703-250-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002046363A00000X
DCPA030379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant