Provider Demographics
NPI:1912446576
Name:PROPHET, SHABNAM (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHABNAM
Middle Name:
Last Name:PROPHET
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHABNAM
Other - Middle Name:
Other - Last Name:ASIFI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:44045 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5101
Mailing Address - Country:US
Mailing Address - Phone:703-858-6000
Mailing Address - Fax:
Practice Address - Street 1:44045 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5101
Practice Address - Country:US
Practice Address - Phone:703-858-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant