Provider Demographics
NPI:1104801844
Name:HARRINGTON STUKUS, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HARRINGTON STUKUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:HARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8318 ARLINGTON BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8318 ARLINGTON BLVD STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5218
Practice Address - Country:US
Practice Address - Phone:703-207-4323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN618102086X0206X
VA0024165377363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00678664OtherRAILROAD MEDICARE
017348M65Medicare PIN
DCP00678664OtherRAILROAD MEDICARE