Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 056647 | GA |
Y | 207QS0010X | Family Doctor - Sports Medicine | 056647 | GA |
NPI | 1093821019 |
---|---|
Provider Name | Dr. Stefanie Lee Shaver |
First Address | Blue Ridge, GA 30513-5718 |
Second Address | Blue Ridge, GA 30513-7139 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2006 |
Last Update Date | 30/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
802792298B | (05) | GA |