Provider Demographics
NPI:1255515300
Name:WARREN, AUBREY LEON (CO)
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:LEON
Last Name:WARREN
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 N CENTER DR
Mailing Address - Street 2:201
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4009
Mailing Address - Country:US
Mailing Address - Phone:757-892-5300
Mailing Address - Fax:757-892-5303
Practice Address - Street 1:6320 N CENTER DR
Practice Address - Street 2:201
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4009
Practice Address - Country:US
Practice Address - Phone:757-892-5300
Practice Address - Fax:757-892-5303
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECO 003925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0482POtherBCBS OF NORTH CAROLINA
NC7701327Medicaid
9190511OtherVIRGINIA PREMIER
384410OtherBCBS OF VIRGINIA
9190511OtherVIRGINIA PREMIER