Basic Information
| Provider Information | |||||||||
| NPI: | 1639651201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGDARAOG | ||||||||
| FirstName: | CRISTY | ||||||||
| MiddleName: | DIAZ | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CAA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANGLEY | ||||||||
| OtherFirstName: | CRISTY | ||||||||
| OtherMiddleName: | DIAZ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRISTY DURAN DIAZ | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 372 WILLIAMSON ST SE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300602483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045420103 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 JOHNSON FY RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048518000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2018 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 8930 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.