Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1174820781 |
---|---|
Provider Name | Jerry Page |
First Address | Atlanta, GA 30309-3934 |
Second Address | Atlanta, GA 30309-3934 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2011 |
Last Update Date | 07/06/2012 |