Healthcare Provider Details

I. General information

NPI: 1457679805
Provider Name (Legal Business Name): XIAOQIN JENNIFER WANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST HX302
LEXINGTON KY
40536-0293
US

IV. Provider business mailing address

800 ROSE ST HX302
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5069
  • Fax: 859-257-5128
Mailing address:
  • Phone: 859-323-5069
  • Fax: 859-257-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR2399
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number336098828
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number48355
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: