MEDICARE: LAURA G WHEELER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	263647	CA

General Provider Information

NPI Number	:	1306857255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA G WHEELER

Provider Business Mailing Address
First Line	:	9894 LA JOLLA FARMS RD
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-1135
Country	:	US
Telephone Number	:	858-453-5902
Fax Number	:

Provider Business Practice Location Address
First Line	:	4520 EXECUTIVE DR
Second Line	:	SUITE 350
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3018
Country	:	US
Telephone Number	:	858-457-0030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	10/19/2012

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