Healthcare Provider Details

I. General information

NPI: 1154409969
Provider Name (Legal Business Name): KARIN E. WAMMACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 E SHAW AVE STE 139
FRESNO CA
93710-8025
US

IV. Provider business mailing address

1551 E SHAW AVE STE 139
FRESNO CA
93710-8025
US

V. Phone/Fax

Practice location:
  • Phone: 559-320-0490
  • Fax: 559-320-0494
Mailing address:
  • Phone: 559-320-0490
  • Fax: 559-320-0494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG48739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: