Provider Demographics
NPI:1023744406
Name:WALLACE-MERCADO, JAMES GAVIN (DNP, MSN, FNP-C)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GAVIN
Last Name:WALLACE-MERCADO
Suffix:
Gender:M
Credentials:DNP, MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:4540 JOHN MARR DR STE B
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3308
Mailing Address - Country:US
Mailing Address - Phone:703-941-6757
Mailing Address - Fax:703-299-1794
Practice Address - Street 1:4540B JOHN MARR DR
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3308
Practice Address - Country:US
Practice Address - Phone:703-941-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185745363LF0000X
TX984504163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice