Healthcare Provider Details

I. General information

NPI: 1811404577
Provider Name (Legal Business Name): AI WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 EDMONDSON AVE STE 200
CATONSVILLE MD
21228-4960
US

IV. Provider business mailing address

6199 HORIZON HEIGHTS DR
KALAMAZOO MI
49009-9105
US

V. Phone/Fax

Practice location:
  • Phone: 443-201-2217
  • Fax: 443-341-4177
Mailing address:
  • Phone: 443-201-2217
  • Fax: 443-341-4177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: