Provider Demographics
NPI:1790004844
Name:HOLDER, CATHERINE GRACE ENGIBOUS (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:GRACE ENGIBOUS
Last Name:HOLDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7036 QUANDER RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307-1612
Mailing Address - Country:US
Mailing Address - Phone:907-240-2084
Mailing Address - Fax:
Practice Address - Street 1:2710 PROSPERITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4358
Practice Address - Country:US
Practice Address - Phone:703-280-2841
Practice Address - Fax:703-280-4773
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60511351363A00000X, 363AM0700X
363A00000X
PA60511351363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0380Medicaid
K163676OtherPTAN