Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | G45357 | CA |
NPI | 1275591554 |
---|---|
Provider Name | Dr. Wanda L Lo |
First Address | San Luis Obispo, CA 93401-3600 |
Second Address | San Luis Obispo, CA 93401-3600 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 05/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
AL1373618 | DEA (01) | CA |