Individual
MIN PARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
11240 WAPLES MILL RD STE 300, FAIRFAX, VA 22030-6078
(571) 407-5042
Mailing address
11240 WAPLES MILL RD STE 300, FAIRFAX, VA 22030-6078
(571) 407-5042
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
0024195870
VA
Other
Enumeration date
01/26/2026
Last updated
01/26/2026
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