Provider Demographics
NPI:1295824324
Name:FAZEKAS, ALICE F (PA)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:F
Last Name:FAZEKAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:E
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3903 S COBB DR SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-8504
Mailing Address - Country:US
Mailing Address - Phone:770-801-4646
Mailing Address - Fax:770-801-5280
Practice Address - Street 1:3903 S COBB DR SE
Practice Address - Street 2:SUITE 200
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8504
Practice Address - Country:US
Practice Address - Phone:770-801-4646
Practice Address - Fax:770-801-5280
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004858363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical