Provider Demographics
NPI:1548545296
Name:SIMONETTI, BLAIR KATHERINE (PA)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:KATHERINE
Last Name:SIMONETTI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BLAIR
Other - Middle Name:KATHERINE
Other - Last Name:SNYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11800 SUNRISE VALLEY DR STE 800
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-5320
Mailing Address - Country:US
Mailing Address - Phone:703-709-1114
Mailing Address - Fax:703-709-1117
Practice Address - Street 1:1831 WIEHLE AVE
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-709-1114
Practice Address - Fax:703-709-1117
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003695363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant