Provider Demographics
NPI:1033282918
Name:GOTTHARDT, MIRIAM ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:ELIZABETH
Last Name:GOTTHARDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MIRIAM
Other - Middle Name:ELIZABETH
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:804-217-7991
Practice Address - Street 1:611 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4415
Practice Address - Country:US
Practice Address - Phone:757-283-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV4687A - C03895Medicare PIN