Provider Demographics
NPI:1316976509
Name:WALLBOM, AGNES SORIANO (MD, MS)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:SORIANO
Last Name:WALLBOM
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Gender:F
Credentials:MD, MS
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Mailing Address - Street 1:11301 WILSHIRE BLVD # 117
Mailing Address - Street 2:GLAVAHS DEPT PM&R
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-1003
Mailing Address - Country:US
Mailing Address - Phone:310-478-3711
Mailing Address - Fax:310-268-4935
Practice Address - Street 1:11301 WILSHIRE BLVD # 117
Practice Address - Street 2:GLAVAHS DEPT PM&R
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:310-268-4935
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG078095208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation