Provider Demographics
NPI:1700547247
Name:MOUSSA, MOUBARAK
Entity Type:Individual
Prefix:
First Name:MOUBARAK
Middle Name:
Last Name:MOUSSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 ADDISON RD S
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-1572
Mailing Address - Country:US
Mailing Address - Phone:240-643-9844
Mailing Address - Fax:
Practice Address - Street 1:1835 ADDISON RD S
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-1572
Practice Address - Country:US
Practice Address - Phone:240-643-9844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCNA20214120376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide