Healthcare Provider Details

I. General information

NPI: 1356616544
Provider Name (Legal Business Name): JENNIFER JEN-WEI WAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S SAN MATEO DR
SAN MATEO CA
94401-3805
US

IV. Provider business mailing address

PO BOX 6102
NOVATO CA
94948-6102
US

V. Phone/Fax

Practice location:
  • Phone: 650-696-4515
  • Fax: 650-696-4626
Mailing address:
  • Phone: 415-884-3415
  • Fax: 415-883-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA128087
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA128087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: