Provider Demographics
NPI:1790399434
Name:AZOFEIFA, FABIAN (PT)
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:AZOFEIFA
Suffix:
Gender:M
Credentials:PT
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 5545
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30916-5545
Mailing Address - Country:US
Mailing Address - Phone:803-349-4118
Mailing Address - Fax:
Practice Address - Street 1:3206 PEACH ORCHARD RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3540
Practice Address - Country:US
Practice Address - Phone:706-798-9323
Practice Address - Fax:706-772-8873
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014812225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist