Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 12850 | GA |
NPI | 1003482621 |
---|---|
Provider Name | Dr. Daria Ravangard |
First Address | Augusta, GA 30912-0004 |
Second Address | Augusta, GA 30912-0006 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2021 |
Last Update Date | 04/06/2021 |