Provider Demographics
NPI:1144864364
Name:ALAM, BUSHRA (PA-C)
Entity type:Individual
Prefix:
First Name:BUSHRA
Middle Name:
Last Name:ALAM
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 1:224D CORNWALL ST NW STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:571-291-9786
Practice Address - Street 1:19441 GOLF VISTA PLAZA SUITE 310 & 230
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8272
Practice Address - Country:US
Practice Address - Phone:703-729-3420
Practice Address - Fax:703-729-3422
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007335363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1144864364Medicaid