Basic Information
| Provider Information | |||||||||
| NPI: | 1568663136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WU | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660640 | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910660640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264470296 | ||||||||
| FaxNumber: | 6264476057 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 NORTH SEPULVEDA BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103792134 | ||||||||
| FaxNumber: | 3103794856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A91185 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A643450 | 05 | CA | MEDICAID |