Healthcare Provider Details

I. General information

NPI: 1245067164
Provider Name (Legal Business Name): FATIMA SHAKOOR BALOCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N US HIGHWAY 1
FORT PIERCE FL
34950-9125
US

IV. Provider business mailing address

827 18TH ST
VERO BEACH FL
32960-6481
US

V. Phone/Fax

Practice location:
  • Phone: 772-468-9900
  • Fax: 772-468-2364
Mailing address:
  • Phone: 772-925-8190
  • Fax: 772-925-8199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119047
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14423
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: