Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 048731 | GA |
N | 2080P0201X | Pediatric Allergist | 048731 | GA |
NPI | 1043285810 |
---|---|
Provider Name | Jaya M. Therattil |
First Address | Augusta, GA 30909-1867 |
Second Address | Augusta, GA 30909-1867 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2006 |
Last Update Date | 14/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000893802B | (05) | GA |
000893802C | (05) | GA |
000893802D | (05) | GA |
G44163 | (02) | GA |
G48731 | (05) | SC |