Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 002629 | GA |
N | 207Q00000X | Family Doctor | 063165 | GA |
Y | 207QS0010X | Family Doctor - Sports Medicine | 063165 | GA |
N | 207QS0010X | Family Doctor - Sports Medicine | 63165 | GA |
NPI | 1053596296 |
---|---|
Provider Name | Dr. Westly Adrian Bailey |
First Address | Suwanee, GA 30024-1284 |
Second Address | Suwanee, GA 30024-1284 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/01/2008 |
Last Update Date | 12/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002629 | RESIDENCY TRAINING PERMIT (01) | GA |