Provider Demographics
NPI:1639686009
Name:MOIN, MAHNOOR (PA)
Entity Type:Individual
Prefix:
First Name:MAHNOOR
Middle Name:
Last Name:MOIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-391-3600
Practice Address - Fax:703-391-3414
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
VA0110006027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1639686009Medicaid