Provider Demographics
NPI:1801459086
Name:EBBING, BROCK ERIC (PA-C)
Entity type:Individual
Prefix:MR
First Name:BROCK
Middle Name:ERIC
Last Name:EBBING
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 1:42010 VILLAGE CENTER PLZ STE 100
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3036
Mailing Address - Country:US
Mailing Address - Phone:703-542-7921
Mailing Address - Fax:
Practice Address - Street 1:42010 VILLAGE CENTER PLZ STE 100
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:20105-3036
Practice Address - Country:US
Practice Address - Phone:703-542-7921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant