Provider Demographics
NPI:1861506495
Name:WAN, LORI (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7910 FROST STREET
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-496-4800
Mailing Address - Fax:858-496-4850
Practice Address - Street 1:7910 FROST STREET
Practice Address - Street 2:SUITE 350
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-496-4800
Practice Address - Fax:858-496-4850
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2011-04-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA62185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH05365Medicare UPIN