Healthcare Provider Details

I. General information

NPI: 1770171977
Provider Name (Legal Business Name): SHUKUFA MANSOURI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHUKUFA ABDUL WAHAB MANSOURI MANSOURI

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 TOWNE VILLAGE DR
CARY NC
27513-8910
US

IV. Provider business mailing address

210 TOWNE VILLAGE DR
CARY NC
27513-8910
US

V. Phone/Fax

Practice location:
  • Phone: 919-859-3373
  • Fax:
Mailing address:
  • Phone: 804-368-4302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007625
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: