Basic Information
| Provider Information | |||||||||
| NPI: | 1700804689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT AGNES PATHOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 3246 | ||||||||
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| City: | PINEDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933503246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594503130 | ||||||||
| FaxNumber: | 5594502035 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 E. HERNDON AVENUE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594503130 | ||||||||
| FaxNumber: | 5594502035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | FANG | ||||||||
| AuthorizedOfficialFirstName: | WEI | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5594303130 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0041880 | 05 | CA | MEDICAID |