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General NPI Number Information
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NPI Number | 1083376230
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Entity Type | Individual
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Provider Name | MOHAMED AMINE STAMBOULI CSA
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Gender | Male
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Dates
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Enumeration Date | 10/05/2021
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Last Update Date | 10/05/2021
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Provider Practice Location Address
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Address Line | 5771 COAKLEY DR
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City | KING GEORGE
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State | VA
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Zip | 22485-2457
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Country | US
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Telephone | 202-749-1404
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Fax |
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Provider Business Mailing Address
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Address Line | 5771 COAKLEY DR
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City | KING GEORGE
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State | VA
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Zip | 22485-2457
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Country | US
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Telephone | 202-749-1404
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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 | 246ZX2200X
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Taxonomy Name | Orthopedic Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 0136000242
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License Number State | VA
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