Provider Demographics
NPI:1871557546
Name:WANEKA, STACY L (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:WANEKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5340 LAS VIRGENES RD APT 7
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-2693
Mailing Address - Country:US
Mailing Address - Phone:310-270-3800
Mailing Address - Fax:818-338-1498
Practice Address - Street 1:2475 TOWNSGATE RD STE 200
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5995
Practice Address - Country:US
Practice Address - Phone:818-338-2540
Practice Address - Fax:818-338-1498
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA68263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA203165086OtherTAX ID
CA203165086OtherTAX ID
H40625Medicare UPIN