Provider Demographics
NPI:1720157829
Name:DAZO, FLAVIANO DELACRUZ (FNP-C)
Entity Type:Individual
Prefix:
First Name:FLAVIANO
Middle Name:DELACRUZ
Last Name:DAZO
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9309 CENTREVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5132
Mailing Address - Country:US
Mailing Address - Phone:703-365-0397
Mailing Address - Fax:703-365-0399
Practice Address - Street 1:9309 CENTREVILLE ROAD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-365-0397
Practice Address - Fax:703-365-0399
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024167153Medicare UPIN