Provider Demographics
NPI:1952942666
Name:MOGHADDASNIA, REZA (PA-C)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:MOGHADDASNIA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 FOX FIRE CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4605
Mailing Address - Country:US
Mailing Address - Phone:703-376-1547
Mailing Address - Fax:
Practice Address - Street 1:8600 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1422
Practice Address - Country:US
Practice Address - Phone:301-896-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00073462086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery