Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | 054495 | GA |
NPI | 1265444228 |
---|---|
Provider Name | Victoria T Mansour |
First Address | Macon, GA 31210-2520 |
Second Address | Macon, GA 31210-2520 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2006 |
Last Update Date | 20/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E85831 | (02) |