Provider Demographics
NPI:1346081718
Name:SHUKRULLAH, SHABNAM (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:SHUKRULLAH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 JONATHAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3592
Mailing Address - Country:US
Mailing Address - Phone:571-888-9339
Mailing Address - Fax:
Practice Address - Street 1:1800 JONATHAN WAY
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3592
Practice Address - Country:US
Practice Address - Phone:571-888-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program