Provider Demographics
NPI:1497227797
Name:ISSA, MUSTAPHA TIMMY (CRNA)
Entity type:Individual
Prefix:MR
First Name:MUSTAPHA
Middle Name:TIMMY
Last Name:ISSA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 ELDERBERRY RUN CV
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3999
Mailing Address - Country:US
Mailing Address - Phone:954-547-9602
Mailing Address - Fax:
Practice Address - Street 1:1403 ELDERBERRY RUN CV
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3999
Practice Address - Country:US
Practice Address - Phone:954-547-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA214261367500000X
SC24769367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered