Provider Demographics
NPI:1700804689
Name:SAINT AGNES PATHOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:SAINT AGNES PATHOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:WEI
Authorized Official - Middle Name:
Authorized Official - Last Name:FANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-430-3130
Mailing Address - Street 1:P.O. BOX 3246
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93350-3246
Mailing Address - Country:US
Mailing Address - Phone:559-450-3130
Mailing Address - Fax:559-450-2035
Practice Address - Street 1:1303 E. HERNDON AVENUE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3309
Practice Address - Country:US
Practice Address - Phone:559-450-3130
Practice Address - Fax:559-450-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0041880Medicaid
CACG2695Medicare PIN
CAZZZ30022ZMedicare PIN