Provider Demographics
NPI:1447875695
Name:YI, BILLIE TAEWOO (PA-C)
Entity type:Individual
Prefix:
First Name:BILLIE
Middle Name:TAEWOO
Last Name:YI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7489 ADAMS PARK CT
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-5724
Mailing Address - Country:US
Mailing Address - Phone:703-674-6888
Mailing Address - Fax:
Practice Address - Street 1:7489 ADAMS PARK CT
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-5724
Practice Address - Country:US
Practice Address - Phone:703-674-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-007275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant