Healthcare Provider Details

I. General information

NPI: 1740053529
Provider Name (Legal Business Name): KETTY C WANG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1667 DOMINICAN WAY STE 230
SANTA CRUZ CA
95065-1560
US

IV. Provider business mailing address

300 PASTEUR DR
STANFORD CA
94305-2200
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-6288
  • Fax: 831-477-9026
Mailing address:
  • Phone: 650-723-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number95027289
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95027289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: