MEDICARE: HAFIDA BOUFALLA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA031026	DC
2	363A00000X	Physician Assistant	0110004409	VA

General Provider Information

NPI Number	:	1538586813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAFIDA BOUFALLA PA-C

Provider Business Mailing Address
First Line	:	6133 LEESBURG PIKE APT 402
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22041-2162
Country	:	US
Telephone Number	:	571-398-8795
Fax Number	:

Provider Business Practice Location Address
First Line	:	6133 LEESBURG PIKE APT 402
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22041-2162
Country	:	US
Telephone Number	:	571-398-8795
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2014
Last Update Date	:	01/30/2024

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