Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | 84505 | GA |
NPI | 1053707042 |
---|---|
Provider Name | Nicholas Mildenhall |
First Address | Marietta, GA 30060-1131 |
Second Address | Marietta, GA 30060-1131 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2015 |
Last Update Date | 27/08/2020 |