NPI age
17 years
Enumerated 2008-08-14
Across 42 active pediatrics providers in Georgia.
1 secondary location on file with NPPES.
| Type | Value | Notes |
|---|---|---|
| 01 (IL) | 036-113313 | STATE LICENSE NUMBER |
| 01 (IL) | 336-074676 | STATE LICENSE, CONTROLLED SUBSTANCE |
| 01 (GA) | 92099 | STATE LICENSE NUMBER |
Part of a multi-provider practice. 39 other active providers share this practice address in NPPES.
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