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General NPI Number Information
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NPI Number | 1972828671
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Entity Type | Individual
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Provider Name | NATHALIE MANTILLA FARFAN M.D
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Gender | Female
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Dates
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Enumeration Date | 04/06/2010
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 1348 WALTON WAY STE 6500
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City | AUGUSTA
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State | GA
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Zip | 30901-5111
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Country | US
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Telephone | 706-722-2118
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Fax |
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Provider Business Mailing Address
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Address Line | 1130 S MICHIGAN AVE APT 3104
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City | CHICAGO
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State | IL
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Zip | 60605-2322
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Country | US
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Telephone | 312-927-5299
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036140788
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 036140788
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 101399
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License Number State | GA
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