Provider Demographics
NPI:1912202664
Name:EZZEKMI-AKSOUH, FELLA (PAC)
Entity Type:Individual
Prefix:
First Name:FELLA
Middle Name:
Last Name:EZZEKMI-AKSOUH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 ELDEN ST
Mailing Address - Street 2:STE #101
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4853
Mailing Address - Country:US
Mailing Address - Phone:703-668-0222
Mailing Address - Fax:703-668-0224
Practice Address - Street 1:201 ELDEN ST
Practice Address - Street 2:STE #101
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4853
Practice Address - Country:US
Practice Address - Phone:703-668-0222
Practice Address - Fax:703-668-0224
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001667363AM0700X
VA0110001167363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical