Basic Information
| Provider Information | |||||||||
| NPI: | 1881297992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAYYAZI | ||||||||
| FirstName: | BABAK | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 RIVERWOOD PKWY SE STE 250 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4706153389 | ||||||||
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| Practice Location | |||||||||
| Address1: | 145 EAGLES WALK STE A | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302817340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709141808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2020 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN254617 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | RN254617 | 05 | GA | MEDICAID |