Healthcare Provider Details

I. General information

NPI: 1649212275
Provider Name (Legal Business Name): WEI CHAO CHANG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

8 BREEZE BRANCH CT APT I
TIMONIUM MD
21093-1219
US

V. Phone/Fax

Practice location:
  • Phone: 410-532-4040
  • Fax: 410-532-4962
Mailing address:
  • Phone: 410-666-8046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002170
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: