Healthcare Provider Details

I. General information

NPI: 1689135998
Provider Name (Legal Business Name): GHAZAL S VAFABAKHSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PALM AVE
JACKSONVILLE FL
32207-8432
US

IV. Provider business mailing address

PO BOX 45278
JACKSONVILLE FL
32232-5278
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-7300
  • Fax: 904-202-7433
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-393-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: