Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207V00000X | Obstetrician & Gynecologist | 052818 | GA |
Y | 207VF0040X | Female Pelvic Medicine and Reconstructive Surgeon | 52818 | GA |
NPI | 1710976048 |
---|---|
Provider Name | Lasonya Roberts-Lopez |
First Address | Austell, GA 30106-6810 |
Second Address | Austell, GA 30106-6810 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2005 |
Last Update Date | 14/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
498562470B | (05) | GA |
H98291 | (02) |