Provider Demographics
NPI:1962289454
Name:ALI, INTISAR
Entity type:Individual
Prefix:
First Name:INTISAR
Middle Name:
Last Name:ALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 BROAD HILL TRL
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7853
Mailing Address - Country:US
Mailing Address - Phone:804-269-6666
Mailing Address - Fax:
Practice Address - Street 1:404 BROAD HILL TRL
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-7853
Practice Address - Country:US
Practice Address - Phone:804-269-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA002-00769270171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor