Healthcare Provider Details

I. General information

NPI: 1023116654
Provider Name (Legal Business Name): RICHARD T.C. WAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W ROBERTS ST
MORGANTOWN KY
42261-7942
US

IV. Provider business mailing address

101 W ROBERTS ST
MORGANTOWN KY
42261-7942
US

V. Phone/Fax

Practice location:
  • Phone: 270-526-3841
  • Fax: 270-526-2651
Mailing address:
  • Phone: 270-526-3841
  • Fax: 270-526-2651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16599
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: