Provider Demographics
NPI:1972534147
Name:AW PATHOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:AW PATHOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-325-2640
Mailing Address - Street 1:1700 C ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-3616
Mailing Address - Country:US
Mailing Address - Phone:661-325-2640
Mailing Address - Fax:661-327-0816
Practice Address - Street 1:2215 TRUXTUN AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-3602
Practice Address - Country:US
Practice Address - Phone:661-632-5483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0098220Medicaid
CAGR0098221Medicaid
CAZZZ28773ZMedicare PIN
CAZZZ28774ZMedicare PIN