Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204F00000X | Transplant Surgeon | G42472 | CA |
N | 208200000X | Surgeon | G42472 | CA |
N | 208600000X | Surgeon | G42472 | CA |
N | 208D00000X | General Practice Physician | G42472 | CA |
NPI | 1548216674 |
---|---|
Provider Name | Ms. Gwenervere Louise Flagg |
First Address | Los Angeles, CA 90009-1177 |
Second Address | Los Angeles, CA 90037-2700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G424720 | (05) | CA |
B57132 | (02) | CA |