Provider Demographics
NPI:1780251157
Name:WAKIMOTO, NICOLE YUKO (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:YUKO
Last Name:WAKIMOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21311 MADRONA AVE STE 100A
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5970
Mailing Address - Country:US
Mailing Address - Phone:310-792-4400
Mailing Address - Fax:424-212-5975
Practice Address - Street 1:21311 MADRONA AVE STE 100A
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5970
Practice Address - Country:US
Practice Address - Phone:310-792-4400
Practice Address - Fax:424-212-5975
Is Sole Proprietor?:No
Enumeration Date:2021-06-05
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA197883207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics