Healthcare Provider Details

I. General information

NPI: 1770610289
Provider Name (Legal Business Name): SONIA J MABOUT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 OLD LEE HWY # 100B-D
FAIRFAX VA
22031-4315
US

IV. Provider business mailing address

2812 OLD LEE HWY # 100B-D
FAIRFAX VA
22031-4315
US

V. Phone/Fax

Practice location:
  • Phone: 571-279-6849
  • Fax: 571-281-8697
Mailing address:
  • Phone: 571-279-6849
  • Fax: 571-281-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-01955
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005904
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: