Provider Demographics
NPI:1023497880
Name:ALGHABRA, JALAL (PA)
Entity type:Individual
Prefix:MR
First Name:JALAL
Middle Name:
Last Name:ALGHABRA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-6233
Mailing Address - Country:US
Mailing Address - Phone:540-373-6647
Mailing Address - Fax:
Practice Address - Street 1:1985 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-6233
Practice Address - Country:US
Practice Address - Phone:540-373-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05866363A00000X
NC0010-05886363AM0700X
MI5601004169363AM0700X
VA0110005989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110005989OtherVA MEDICAL BOARD
NC0010-05866OtherNC MEDICAL BOARD