MEDICARE: SARA CLOUGH PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110005420	VA

General Provider Information

NPI Number	:	1699128058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA CLOUGH PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	PO BOX 75420
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21275-5420
Country	:	US
Telephone Number	:	703-383-6469
Fax Number	:	703-385-1062

Provider Business Practice Location Address
First Line	:	1715 N GEORGE MASON DR STE 504
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205-3670
Country	:	US
Telephone Number	:	703-525-2200
Fax Number	:	703-810-5423

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	08/08/2023

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