Healthcare Provider Details

I. General information

NPI: 1285030189
Provider Name (Legal Business Name): LORRAINE CF WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 30TH ST
LOS ANGELES CA
90007-3320
US

IV. Provider business mailing address

226 BENICIA RD
DIAMOND BAR CA
91765-1601
US

V. Phone/Fax

Practice location:
  • Phone: 909-272-7782
  • Fax:
Mailing address:
  • Phone: 909-272-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA52930
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: