Provider Demographics
NPI:1194944900
Name:AW CYTOHISTOLOGY LAB
Entity type:Organization
Organization Name:AW CYTOHISTOLOGY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-325-2640
Mailing Address - Street 1:11108 ZENAIDA WAY
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-2928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 C ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-3616
Practice Address - Country:US
Practice Address - Phone:661-325-2640
Practice Address - Fax:661-327-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50093291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A500931Medicaid
CALAB16538FMedicaid
CALAB16538FMedicaid
CA00A500930Medicare ID - Type UnspecifiedMEDICARE