NPI age
17 years
Enumerated 2009-04-14
Across 1881 active specialist providers in Georgia.
| Type | Value | Notes |
|---|---|---|
| 01 (GA) | 017843 | STATE LICENSE |
| 05 (GA) | 00114067A | |
| 01 | D30028 | UPIN |
Single-site organization. Only one practice location on file.
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