Healthcare Provider Details

I. General information

NPI: 1235841818
Provider Name (Legal Business Name): HAKIM V MAURICE STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

4063 LAUREL BEND DR
SNELLVILLE GA
30039-4125
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-4411
  • Fax:
Mailing address:
  • Phone: 404-428-4453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number11402
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: