Healthcare Provider Details

I. General information

NPI: 1790311009
Provider Name (Legal Business Name): MARIAM YAKTIEEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

IV. Provider business mailing address

4902 SAUQUOIT LN
ANNANDALE VA
22003-5142
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-8000
  • Fax:
Mailing address:
  • Phone: 571-205-9426
  • Fax:

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: