Provider Demographics
NPI:1679755045
Name:WASSON, ELIZABETH SCOTT (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SCOTT
Last Name:WASSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-6399
Practice Address - Fax:707-967-5915
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126381207QA0505X, 207QG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300432OtherBOARD CERTIFICATION-INTERNAL MEDICINE
CAA126381OtherPHYSICIAN AND SURGEON
CACA211575Medicare PIN
LAPGY.2.TUL-IMOtherLA LICENSE NUMBER
MS08123015Medicaid
LA4P0277061Medicare PIN