Healthcare Provider Details

I. General information

NPI: 1205164217
Provider Name (Legal Business Name): MAZEN SHAFIQ FAKHOURI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST ORTHOPAEDIC CLINIC
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST # OR6000
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2847
  • Fax:
Mailing address:
  • Phone: 706-721-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005712
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005712
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: