Provider Demographics
NPI:1336277730
Name:WARGULA, ALANNA L (DPM)
Entity Type:Individual
Prefix:
First Name:ALANNA
Middle Name:L
Last Name:WARGULA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ALANNA
Other - Middle Name:L
Other - Last Name:PANKOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:175 PARK ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4803
Mailing Address - Country:US
Mailing Address - Phone:707-263-9595
Mailing Address - Fax:707-263-5576
Practice Address - Street 1:1255 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4663
Practice Address - Country:US
Practice Address - Phone:707-596-2660
Practice Address - Fax:707-263-5576
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4707213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA114936Medicare PIN
000E47070Medicare PIN
CAE4707OtherPODIATRY LICENSE
000E47070Medicare PIN
BBB32236BOtherMEDICARE SUBMITTER NUMBER
33-1156430OtherEID NUMBER