Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 024462 | GA |
NPI | 1760501555 |
---|---|
Provider Name | Phyllis Mansour |
First Address | Atlanta, GA 30324 |
Second Address | Atlanta, GA 30324 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2007 |
Last Update Date | 08/07/2007 |