Provider Demographics
NPI:1780614693
Name:ABREU, WANDA (MD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:ABREU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N CHINA LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3131
Mailing Address - Country:US
Mailing Address - Phone:760-499-3855
Mailing Address - Fax:
Practice Address - Street 1:1111 N CHINA LAKE BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3131
Practice Address - Country:US
Practice Address - Phone:760-499-3855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83687208000000X
NY291708208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095040Medicaid
CAI09119Medicare UPIN
CAGR0095040Medicaid