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General NPI Number Information
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NPI Number | 1003518259
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Entity Type | Individual
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Provider Name | MOHAMMED MOUTCHOU LSA
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Gender | Male
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Dates
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Enumeration Date | 03/21/2023
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Last Update Date | 03/21/2023
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Provider Practice Location Address
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Address Line | 2837 CHABLIS CIR
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City | WOODBRIDGE
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State | VA
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Zip | 22192-1947
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Country | US
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Telephone | 434-284-0346
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Fax |
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Provider Business Mailing Address
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Address Line | 2837 CHABLIS CIR
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City | WOODBRIDGE
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State | VA
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Zip | 22192-1947
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Country | US
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Telephone | 434-284-0346
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 0136000723
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License Number State | VA
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