Healthcare Provider Details

I. General information

NPI: 1477158061
Provider Name (Legal Business Name): DANG WANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 W ANNANDALE LN
AZUSA CA
91702-1432
US

IV. Provider business mailing address

342 W ANNANDALE LN
AZUSA CA
91702-1432
US

V. Phone/Fax

Practice location:
  • Phone: 323-416-9092
  • Fax:
Mailing address:
  • Phone: 323-416-9092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number1477158061
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number68011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: