Basic Information
| Provider Information | |||||||||
| NPI: | 1033478755 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED WOMEN'S UROLOGY AND GYNECOLOGY, PLLC | ||||||||
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| OtherOrganizationName: | ADVANCED UROGYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2501 N ORANGE AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328044603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078989804 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2012 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4078989804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED WOMEN'S UROLOGY AND GYNECOLOGY, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.