Provider Demographics
NPI:1174692362
Name:EGAN, KERRY A (DC)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:EGAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 MOZART BRIGADE LN APT E
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3971
Mailing Address - Country:US
Mailing Address - Phone:703-473-4145
Mailing Address - Fax:
Practice Address - Street 1:4200 MOZART BRIGADE LN APT E
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3971
Practice Address - Country:US
Practice Address - Phone:703-473-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010776111N00000X
VA0104556828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232480OtherBCBS GROUP NUMBER