Provider Demographics
NPI:1770610289
Name:MABOUT, SONIA J (PA-C)
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:J
Last Name:MABOUT
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 1:2812 OLD LEE HWY # 100B-D
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4315
Mailing Address - Country:US
Mailing Address - Phone:571-279-6849
Mailing Address - Fax:571-281-8697
Practice Address - Street 1:2812 OLD LEE HWY # 100B-D
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4315
Practice Address - Country:US
Practice Address - Phone:571-279-6849
Practice Address - Fax:571-281-8697
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01955363AM0700X
VA0110005904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCK832AMedicare PIN