Provider Demographics
NPI:1194942474
Name:IWU, ALICE NKECHI (PA)
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:NKECHI
Last Name:IWU
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1101 SAM PERRY BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4467
Mailing Address - Country:US
Mailing Address - Phone:540-374-3200
Mailing Address - Fax:540-374-3210
Practice Address - Street 1:1101 SAM PERRY BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4467
Practice Address - Country:US
Practice Address - Phone:540-374-3200
Practice Address - Fax:540-374-3210
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2009-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY010413-1363AS0400X
VA0110002690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194942474Medicare PIN