Provider Demographics
NPI:1154409969
Name:WAMMACK, KARIN E (MD)
Entity type:Individual
Prefix:
First Name:KARIN
Middle Name:E
Last Name:WAMMACK
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 1:1551 E SHAW AVE STE 139
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8025
Mailing Address - Country:US
Mailing Address - Phone:559-320-0490
Mailing Address - Fax:559-320-0494
Practice Address - Street 1:1551 E SHAW AVE STE 139
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8025
Practice Address - Country:US
Practice Address - Phone:559-320-0490
Practice Address - Fax:559-320-0494
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G487390Medicaid
CA00G487390Medicaid
F43183Medicare UPIN