Healthcare Provider Details

I. General information

NPI: 1376955831
Provider Name (Legal Business Name): MIO YANAGISAWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1279 HIGHWAY 54 W STE 100
FAYETTEVILLE GA
30214-4551
US

IV. Provider business mailing address

1365 CLIFTON RD NE BLDG C
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-5710
  • Fax:
Mailing address:
  • Phone: 404-778-3307
  • Fax: 404-778-4255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number85457
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD492547
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: