Provider Demographics
NPI:1063287738
Name:ABOUHAIB, ABDALLA (SO-ATP)
Entity type:Individual
Prefix:
First Name:ABDALLA
Middle Name:
Last Name:ABOUHAIB
Suffix:
Gender:M
Credentials:SO-ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D RECONNAISSANCE BATTALION
Mailing Address - Street 2:PCS BOX 20138
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0138
Mailing Address - Country:US
Mailing Address - Phone:910-440-7703
Mailing Address - Fax:
Practice Address - Street 1:2D RECONNAISSANCE BN
Practice Address - Street 2:PCS 20138
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:910-440-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02238959AA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman