NPI age
19 years
Enumerated 2006-08-11
Across 661 active general practice providers in Georgia.
| Type | Value | Notes |
|---|---|---|
| 01 (GA) | 010715 | STATE LICENSE |
| 05 (GA) | 00010458A |
Solo or small practice. No other active providers share this practice address in NPPES. This provider is listed as a sole proprietor.
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