Healthcare Provider Details

I. General information

NPI: 1376999391
Provider Name (Legal Business Name): KHOLOUD AJIB PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 CAMINO REAL STE 300
BOCA RATON FL
33433-5511
US

IV. Provider business mailing address

1094 MILITARY TRL
JUPITER FL
33458-7021
US

V. Phone/Fax

Practice location:
  • Phone: 561-487-4110
  • Fax: 941-342-8893
Mailing address:
  • Phone: 561-622-6111
  • Fax: 855-215-9930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: