Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CHIR009280 | GA |
NPI | 1487086070 |
---|---|
Provider Name | Dr. Michael Agostino Longyear |
First Address | Marietta, GA 30060-2943 |
Second Address | Marietta, GA 30060-2943 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2013 |
Last Update Date | 28/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NCE 568 B 621 | (02) | NC |