Provider Demographics
NPI:1720796659
Name:FATHE-AAZAM, ANDISHEH (RBT)
Entity type:Individual
Prefix:
First Name:ANDISHEH
Middle Name:
Last Name:FATHE-AAZAM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4198 YATESVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-1539
Mailing Address - Country:US
Mailing Address - Phone:831-201-8774
Mailing Address - Fax:
Practice Address - Street 1:4198 YATESVILLE HWY
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-1539
Practice Address - Country:US
Practice Address - Phone:831-201-8774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician