Basic Information
| Provider Information | |||||||||
| NPI: | 1114169760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLNER | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2625 W ALAMEDA AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107947700 | ||||||||
| FaxNumber: | 8182608718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2009 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | A113187 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208800000X | A113187 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.