Provider Demographics
NPI:1538903745
Name:ABUGHRARA, HAITAM M
Entity type:Individual
Prefix:MR
First Name:HAITAM
Middle Name:M
Last Name:ABUGHRARA
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 1:5422 ECHOLS AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1343
Mailing Address - Country:US
Mailing Address - Phone:571-494-7896
Mailing Address - Fax:
Practice Address - Street 1:5422 ECHOLS AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1343
Practice Address - Country:US
Practice Address - Phone:571-494-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAB65301570343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)