Basic Information
| Provider Information | |||||||||
| NPI: | 1720242068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIRAU-ROSALY | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | DEL CARMEN | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1499 WALTON WAY STE 1400 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067246100 | ||||||||
| FaxNumber: | 7067217016 | ||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
| Address2: | 9040 REID ST. | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
| FaxNumber: | 2539683278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207Q00000X | 01059043A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 077153 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.