Individual
IA Y KUE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
115 LEE BYRD RD, LOGANVILLE, GA 30052-2310
(707) 554-4717
(770) 554-4681
Mailing address
115 LEE BYRD RD, LOGANVILLE, GA 30052-2310
(707) 554-4717
(770) 554-4681
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
5101015717
MI
207Q00000X
Family Medicine Physician
Primary
95143
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
45-1674932
COMMERCIAL FEIN
MI
01
—
700H273300
BLUE CROSS BLUE SHEILD
MI
Enumeration date
12/29/2005
Last updated
01/11/2024
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