Provider Demographics
NPI:1801187083
Name:LAURIE M. WOLL D.O.
Entity Type:Organization
Organization Name:LAURIE M. WOLL D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEHNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-625-5567
Mailing Address - Street 1:9301 CENTRAL AVE., SUITE 201
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763
Mailing Address - Country:US
Mailing Address - Phone:909-625-5567
Mailing Address - Fax:909-621-4900
Practice Address - Street 1:9301 CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2446
Practice Address - Country:US
Practice Address - Phone:909-625-5567
Practice Address - Fax:909-621-4900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17704363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty