Provider Demographics
NPI:1275591554
Name:LO, WANDA L (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:L
Last Name:LO
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Gender:F
Credentials:MD
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Mailing Address - Street 1:1235 OSOS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3600
Mailing Address - Country:US
Mailing Address - Phone:805-549-0888
Mailing Address - Fax:805-549-8463
Practice Address - Street 1:1235 OSOS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3600
Practice Address - Country:US
Practice Address - Phone:805-549-0888
Practice Address - Fax:805-549-8463
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
CAG453572080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAL1373618OtherDEA