Individual
MIRIAM JACQUELINE NICOLASA CUSICANQUI MONRROY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1715 N GEORGE MASON DR, SUITE 501, ARLINGTON, VA 22205-3609
(703) 527-4466
(703) 552-1326
Mailing address
4710 OLD DOMINION DR, ARLINGTON, VA 22207-3527
(703) 527-4466
(703) 552-1326
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0101241806
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
132601
MEDICARE PTAN
VA
05
—
1497945174
—
VA
05
—
7100033620
—
KY
Enumeration date
07/28/2007
Last updated
08/10/2016
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