Healthcare Provider Details

I. General information

NPI: 1639500945
Provider Name (Legal Business Name): AYESHA IQBAL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 CANTON RD NE STE 300
MARIETTA GA
30060
US

IV. Provider business mailing address

711 CANTON RD NE STE 300
MARIETTA GA
30060-8949
US

V. Phone/Fax

Practice location:
  • Phone: 678-741-5000
  • Fax: 678-819-4280
Mailing address:
  • Phone: 678-741-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number007054
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: