Provider Demographics
NPI:1376227751
Name:PUTROS, WALA (LE)
Entity Type:Individual
Prefix:
First Name:WALA
Middle Name:
Last Name:PUTROS
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 E MCFADDEN AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-4648
Mailing Address - Country:US
Mailing Address - Phone:714-617-5463
Mailing Address - Fax:951-531-9465
Practice Address - Street 1:1780 E MCFADDEN AVE STE 115
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4648
Practice Address - Country:US
Practice Address - Phone:714-617-5463
Practice Address - Fax:951-531-9465
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist