Basic Information
| Provider Information | |||||||||
| NPI: | 1700076940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULTANA | ||||||||
| FirstName: | AQFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3502 W NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392134454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013645142 | ||||||||
| FaxNumber: | 6013645159 | ||||||||
| Practice Location | |||||||||
| Address1: | 3502 W NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392134454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013645142 | ||||||||
| FaxNumber: | 6013645159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207QA0505X | 21234 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07331261 | 05 | MS | MEDICAID | 09964 | 05 | LA | MEDICAID |