Healthcare Provider Details

I. General information

NPI: 1154268803
Provider Name (Legal Business Name): KHALID MUQADDIM II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CLEARFIELD AVE
CHESAPEAKE VA
23320-4017
US

IV. Provider business mailing address

301 CLEARFIELD AVE
CHESAPEAKE VA
23320-4017
US

V. Phone/Fax

Practice location:
  • Phone: 562-293-7695
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606653
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: