Provider Demographics
NPI:1366910358
Name:NEWMAN, GARY MICHAEL (PTA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:NEWMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12704 WIMBLEY LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5084
Mailing Address - Country:US
Mailing Address - Phone:703-853-3902
Mailing Address - Fax:
Practice Address - Street 1:6929 MATTHEW PL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3607
Practice Address - Country:US
Practice Address - Phone:703-813-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605209225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant