Provider Demographics
NPI:1285884007
Name:DETRICK, MIN JIN JUNG (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MIN JIN
Middle Name:JUNG
Last Name:DETRICK
Suffix:
Gender:F
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 1:3300 GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3307
Mailing Address - Country:US
Mailing Address - Phone:703-776-4001
Mailing Address - Fax:703-776-7113
Practice Address - Street 1:8100 BOONE BLVD STE 700
Practice Address - Street 2:
Practice Address - City:TYSONS
Practice Address - State:VA
Practice Address - Zip Code:22182-2683
Practice Address - Country:US
Practice Address - Phone:703-531-2269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01553363A00000X
VA0110003714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759246Medicare PIN