Basic Information
| Provider Information | |||||||||
| NPI: | 1184653875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGAR | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W. CENTURY BLVD | ||||||||
| Address2: | #400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107948285 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | STE B-186 CHS | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900953075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107948285 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 06/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | G48534 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00G485340 | 05 | CA | MEDICAID |