Wagoner, Genesa

Wagoner, Genesa is an individual health care provider with primary practice located at 1294 W 6Th St Suite 104, San Pedro CA 90731-2987. She recently has only one registered license in Allopathic & Osteopathic Physicians / Pediatrics, which is considered as her primary health care specialty. Wagoner, Genesa can be contacted via phone (310) 548-9118.

Contact Information

Primary practice address
1294 W 6Th St Suite 104 San Pedro CA 90731-2987
Phone: (310) 548-9118
Fax: (310) 548-1310
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Pediatrics 208000000X G77273 California

Profile Details

NPI number 1518074160
LBN Legal business name Wagoner, Genesa
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Aug 23rd, 2006
Last updated Dec 2nd, 2011 - about 15 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1518074160 NPPES
California MEDICAID 00G772730

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