Healthcare Provider Details

I. General information

NPI: 1447585658
Provider Name (Legal Business Name): CHARLES K LWANG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 NOTTINGHAM CT APT 509
LYNN MA
01905-3131
US

IV. Provider business mailing address

28 NOTTINGHAM CT APT 509
LYNN MA
01905-3131
US

V. Phone/Fax

Practice location:
  • Phone: 617-642-9006
  • Fax:
Mailing address:
  • Phone: 617-642-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2262126
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number014846-22
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: