=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770177982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. NISMA ZBIB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2021
-----------------------------------------------------
Last Update Date | 10/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 HOSPITAL DR
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31217-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-464-1359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 BROOKLINE CT
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-6434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-625-7477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10487
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------