Healthcare Provider Details

I. General information

NPI: 1083154389
Provider Name (Legal Business Name): MANOUCHEHR ATAEI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3357B CORRIDOR MARKETPLACE
LAUREL MD
20724-2381
US

IV. Provider business mailing address

700 GEIPE RD STE 200
CATONSVILLE MD
21228-4176
US

V. Phone/Fax

Practice location:
  • Phone: 301-497-1820
  • Fax:
Mailing address:
  • Phone: 410-744-0661
  • Fax: 410-744-8036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006284
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: