Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | MT003693 | GA |
NPI | 1366065823 |
---|---|
Provider Name | Rena Wilson |
First Address | Alpharetta, GA 30004-5932 |
Second Address | Alpharetta, UNITED STATES 30004 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2020 |
Last Update Date | 19/05/2020 |