Provider Demographics
NPI:1972000404
Name:MUSTAFA, MALAKA
Entity Type:Individual
Prefix:
First Name:MALAKA
Middle Name:
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 BEAVER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-2552
Mailing Address - Country:US
Mailing Address - Phone:706-847-5252
Mailing Address - Fax:
Practice Address - Street 1:303 PARKWAY DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312
Practice Address - Country:US
Practice Address - Phone:404-265-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8714363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1972000404OtherEMERGENCY DEPARTMENT