Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207V00000X | Obstetrician & Gynecologist | 2006-00745 | NC |
N | 207V00000X | Obstetrician & Gynecologist | 46727 | MN |
Y | 207VE0102X | Reproductive Endocrinologist | 70748 | GA |
NPI | 1003895780 |
---|---|
Provider Name | Dr. Larisa P Gavrilova-Jordan |
First Address | Augusta, GA 30901-2603 |
Second Address | Augusta, GA 30912-0004 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2006 |
Last Update Date | 24/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5909224 | (05) | NC |
891448600 | (05) | MN |
I11927 | (02) |