Healthcare Provider Details

I. General information

NPI: 1366061772
Provider Name (Legal Business Name): TONY WANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VAN NESS AVE STE 1120
SAN FRANCISCO CA
94109-6919
US

IV. Provider business mailing address

272 BEECHWOOD LN
YORKTOWN HEIGHTS NY
10598-5328
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-6000
  • Fax:
Mailing address:
  • Phone: 914-483-9824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: