Provider Demographics
NPI:1730499062
Name:QAZIZADA, WAGMA (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:WAGMA
Middle Name:
Last Name:QAZIZADA
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:PO BOX 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-720-0599
Mailing Address - Fax:904-376-4036
Practice Address - Street 1:14534 OLD SAINT AUGUSTINE RD STE 3420
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2645
Practice Address - Country:US
Practice Address - Phone:904-493-8001
Practice Address - Fax:904-388-0852
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105608363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004252400Medicaid
FLEY573XMedicare PIN