Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0201X | Pediatric Allergist | 009305 | GA |
NPI | 1497866123 |
---|---|
Provider Name | Betty Wray |
First Address | Augusta, GA 30901-2602 |
Second Address | Augusta, GA 30912-0004 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 06/05/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000024395A | (05) | GA |
903428 | (05) | SC |
D31451 | (02) |