Active NPI
Genesa Wagoner, M.D.
- Pediatrics Physician
- San Pedro, CA
National Provider Identifier
1518074160
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- G77273
- Practice address
- 1294 W 6TH St
Suite 104
San Pedro, CA 90731-2987 - Phone
- (310) 548-9118
- Fax
- (310) 548-1310
- NPI assigned
- Aug 23, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | G77273 | CA | Primary |
Addresses
Primary practice location
1294 W 6TH St
Suite 104
San Pedro, CA 90731-2987
Mailing address
1294 W 6TH St
Suite 104
San Pedro, CA 90731-2987
Phone (310) 548-9118
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00G772730 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| G77273 | CA | MD | Pediatrics Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156291200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1322784000000",
"number": "1518074160",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1294 W 6TH ST",
"address_2": "SUITE 104",
"city": "SAN PEDRO",
"state": "CA",
"postal_code": "907312987",
"telephone_number": "310-548-9118",
"fax_number": "310-548-1310"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1294 W 6TH ST",
"address_2": "SUITE 104",
"city": "SAN PEDRO",
"state": "CA",
"postal_code": "907312987",
"telephone_number": "310-548-9118",
"fax_number": "310-548-1310"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGONER",
"first_name": "GENESA",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-23",
"last_updated": "2011-12-02",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "CA",
"license": "G77273",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00G772730",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in San Pedro, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.