Provider Demographics
NPI:1164178372
Name:BOUCTEB, HOSSAM IDRISSI
Entity Type:Individual
Prefix:
First Name:HOSSAM
Middle Name:IDRISSI
Last Name:BOUCTEB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 HYANNIS DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-8331
Mailing Address - Country:US
Mailing Address - Phone:919-633-2324
Mailing Address - Fax:
Practice Address - Street 1:4109 WAKE FOREST RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6262
Practice Address - Country:US
Practice Address - Phone:919-322-0042
Practice Address - Fax:919-322-0041
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP21044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist