Healthcare Provider Details

I. General information

NPI: 1518074160
Provider Name (Legal Business Name): GENESA WAGONER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1294 W 6TH ST SUITE 104
SAN PEDRO CA
90731-2987
US

IV. Provider business mailing address

1294 W 6TH ST SUITE 104
SAN PEDRO CA
90731-2987
US

V. Phone/Fax

Practice location:
  • Phone: 310-548-9118
  • Fax: 310-548-1310
Mailing address:
  • Phone: 310-548-9118
  • Fax: 310-548-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG77273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: