Healthcare Provider Details

I. General information

NPI: 1730499062
Provider Name (Legal Business Name): WAGMA QAZIZADA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14534 OLD SAINT AUGUSTINE RD STE 3420
JACKSONVILLE FL
32258-2645
US

IV. Provider business mailing address

PO BOX 43667
JACKSONVILLE FL
32203-3667
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-8001
  • Fax: 904-388-0852
Mailing address:
  • Phone: 904-720-0599
  • Fax: 904-376-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105608
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: