Healthcare Provider Details

I. General information

NPI: 1174901003
Provider Name (Legal Business Name): QIUJUAN WANG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HHC CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-4306
  • Fax: 860-696-5140
Mailing address:
  • Phone: 860-972-5507
  • Fax: 860-972-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60989637
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113633
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004328
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7698
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number018589
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006085
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: