Healthcare Provider Details

I. General information

NPI: 1700335627
Provider Name (Legal Business Name): JUMA GASSIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7949 ROSWELL RD. APT. F
ATLANTA GA
30350
US

IV. Provider business mailing address

7949 ROSWELL RD APT. F
ATLANTA GA
30350-7045
US

V. Phone/Fax

Practice location:
  • Phone: 404-483-2021
  • Fax:
Mailing address:
  • Phone: 404-483-2021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number11-220
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: