Healthcare Provider Details

I. General information

NPI: 1790004844
Provider Name (Legal Business Name): CATHERINE GRACE ENGIBOUS HOLDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4358
US

IV. Provider business mailing address

7036 QUANDER RD
ALEXANDRIA VA
22307-1612
US

V. Phone/Fax

Practice location:
  • Phone: 703-280-2841
  • Fax: 703-280-4773
Mailing address:
  • Phone: 907-240-2084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60511351
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60511351
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60511351
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: