Healthcare Provider Details

I. General information

NPI: 1497227797
Provider Name (Legal Business Name): MUSTAPHA TIMMY ISSA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 DACULA RD UNIT 145
DACULA GA
30019-0102
US

IV. Provider business mailing address

470 DACULA RD UNIT 145
DACULA GA
30019-0102
US

V. Phone/Fax

Practice location:
  • Phone: 954-547-9602
  • Fax:
Mailing address:
  • Phone: 954-547-9602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24769
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number214261
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: