Provider Demographics
NPI:1114207032
Name:RADTKE, FAIROZ MATJAN (PA-C)
Entity Type:Individual
Prefix:
First Name:FAIROZ
Middle Name:MATJAN
Last Name:RADTKE
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 1:5850 EUBANK BLVD NE
Mailing Address - Street 2:STE B32
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6127
Mailing Address - Country:US
Mailing Address - Phone:678-513-2228
Mailing Address - Fax:678-513-1147
Practice Address - Street 1:5400 LAUREL SPRINGS PKWY
Practice Address - Street 2:SUITE 1401
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6056
Practice Address - Country:US
Practice Address - Phone:678-513-2228
Practice Address - Fax:678-513-1147
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003766363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical