Healthcare Provider Details

I. General information

NPI: 1770567679
Provider Name (Legal Business Name): TRICIA ELAINE VANWAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRICIA ELAINE VANWAGNER LAWS M.D.

II. Dates (important events)

Enumeration Date: 12/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL CAMP PENDLETON FAMILY MEDICINE CLINIC BOX 555191
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

1601 S NEVADA ST
OCEANSIDE CA
92054-5901
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1400
  • Fax:
Mailing address:
  • Phone: 760-231-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA78761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: