Provider Demographics
NPI:1639651201
Name:MAGDARAOG, CRISTY DIAZ (CAA)
Entity Type:Individual
Prefix:
First Name:CRISTY
Middle Name:DIAZ
Last Name:MAGDARAOG
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:CRISTY
Other - Middle Name:DIAZ
Other - Last Name:LANGLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRISTY DURAN DIAZ
Mailing Address - Street 1:372 WILLIAMSON ST SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2483
Mailing Address - Country:US
Mailing Address - Phone:404-542-0103
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1611
Practice Address - Country:US
Practice Address - Phone:404-851-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8930367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant