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General NPI Number Information
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NPI Number | 1770610289
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Entity Type | Individual
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Provider Name | SONIA J MABOUT PA-C
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Gender | Female
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 06/13/2020
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Provider Practice Location Address
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Address Line | 2812 OLD LEE HWY # 100B-D
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City | FAIRFAX
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State | VA
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Zip | 22031-4315
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Country | US
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Telephone | 571-279-6849
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Fax | 571-281-8697
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Provider Business Mailing Address
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Address Line | 2812 OLD LEE HWY # 100B-D
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City | FAIRFAX
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State | VA
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Zip | 22031-4315
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Country | US
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Telephone | 571-279-6849
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Fax | 571-281-8697
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0010-01955
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110005904
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License Number State | VA
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