Provider Demographics
NPI:1831841618
Name:WAGO, NOBUHIRO
Entity type:Individual
Prefix:
First Name:NOBUHIRO
Middle Name:
Last Name:WAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 MOUNT WILKINSON PKWY SE APT NO902
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3637
Mailing Address - Country:US
Mailing Address - Phone:770-333-6198
Mailing Address - Fax:
Practice Address - Street 1:1295 W SPRING ST SE STE 230
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-3676
Practice Address - Country:US
Practice Address - Phone:770-436-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist