Provider Demographics
NPI:1881297992
Name:FAYYAZI, BABAK (NP)
Entity type:Individual
Prefix:
First Name:BABAK
Middle Name:
Last Name:FAYYAZI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 RIVERWOOD PKWY SE STE 250
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3304
Mailing Address - Country:US
Mailing Address - Phone:470-615-3389
Mailing Address - Fax:
Practice Address - Street 1:145 EAGLES WALK STE A
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7340
Practice Address - Country:US
Practice Address - Phone:770-914-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN254617363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN254617Medicaid