Provider Demographics
NPI:1922621473
Name:POURAKBAR, MOJGAN
Entity Type:Individual
Prefix:
First Name:MOJGAN
Middle Name:
Last Name:POURAKBAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030A MACHEN RD
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2217
Mailing Address - Country:US
Mailing Address - Phone:703-953-7202
Mailing Address - Fax:
Practice Address - Street 1:1319 SHEPARD DR
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-4487
Practice Address - Country:US
Practice Address - Phone:703-953-7202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001283045163WD1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD1100XNursing Service ProvidersRegistered NurseDialysis, PeritonealGroup - Single Specialty