Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 058113 | GA |
NPI | 1003937509 |
---|---|
Provider Name | Nana Kwaku Opare |
First Address | Atlanta, GA 30331-2034 |
Second Address | Atlanta, GA 30331-2034 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2007 |
Last Update Date | 28/11/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
058113 | GEORGIA MEDICAL LICENSE (01) | GA |
A52924 | (02) | |
AS3173200 | FEDERAL DEA (01) |