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General NPI Number Information
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NPI Number | 1902184062
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Entity Type | Individual
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Provider Name | MARIAN J WYMORE M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/23/2011
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Last Update Date | 07/23/2011
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Provider Practice Location Address
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Address Line | 27336 SUNNYRIDGE RD
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City | PALOS VERDES PENINSULA
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State | CA
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Zip | 90274-4037
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Country | US
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Telephone | 310-780-0155
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Fax | 310-377-8874
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Provider Business Mailing Address
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Address Line | 27336 SUNNYRIDGE RD
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City | PALOS VERDES PENINSULA
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State | CA
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Zip | 90274-4037
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Country | US
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Telephone | 310-780-0155
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Fax | 310-377-8874
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | G50846
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License Number State | CA
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