Healthcare Provider Details

I. General information

NPI: 1538898044
Provider Name (Legal Business Name): WAJIHA FAROOQ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 THREE RIVERS DR NE
ROME GA
30161-4999
US

IV. Provider business mailing address

5 CRESTMONT CT SW
ROME GA
30165-4154
US

V. Phone/Fax

Practice location:
  • Phone: 706-232-1300
  • Fax:
Mailing address:
  • Phone: 706-844-5072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11035
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: