Healthcare Provider Details

I. General information

NPI: 1629313515
Provider Name (Legal Business Name): SIMSON WANG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 10/21/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 OCEAN PARK BLVD UNIT 358
SANTA MONICA CA
90405-3004
US

IV. Provider business mailing address

3019 OCEAN PARK BLVD UNIT 358
SANTA MONICA CA
90405-3004
US

V. Phone/Fax

Practice location:
  • Phone: 310-795-5988
  • Fax:
Mailing address:
  • Phone: 310-795-5988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4332
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: