Provider Demographics
NPI:1760008452
Name:WANGANIA, GRETA
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:WANGANIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1223
Mailing Address - Country:US
Mailing Address - Phone:909-621-6708
Mailing Address - Fax:
Practice Address - Street 1:775 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1223
Practice Address - Country:US
Practice Address - Phone:909-621-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95043891163W00000X
CA95016974363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty