Healthcare Provider Details

I. General information

NPI: 1235794009
Provider Name (Legal Business Name): PHILIP WAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SBCH, MEDICAL EDUCATION 400 W PUEBLO STREET
SANTA BARBARA CA
93015
US

IV. Provider business mailing address

SBCH, MEDICAL EDUCATION 400 W PUEBLO STREET
SANTA BARBARA CA
93015
US

V. Phone/Fax

Practice location:
  • Phone: 805-569-7315
  • Fax: 805-569-8358
Mailing address:
  • Phone: 805-569-7315
  • Fax: 805-569-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number20A19665
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A19665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: