Provider Demographics
NPI:1306857255
Name:WHEELER, LAURA G
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:WHEELER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:G
Other - Last Name:MCCALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9894 LA JOLLA FARMS RD
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1135
Mailing Address - Country:US
Mailing Address - Phone:858-453-5902
Mailing Address - Fax:
Practice Address - Street 1:4520 EXECUTIVE DR
Practice Address - Street 2:SUITE 350
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3018
Practice Address - Country:US
Practice Address - Phone:858-457-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263647363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics