Healthcare Provider Details

I. General information

NPI: 1477508281
Provider Name (Legal Business Name): CONNIE JUNLING WANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WABASHA ST S
SAINT PAUL MN
55107-1805
US

IV. Provider business mailing address

701 PARK AVE SHAPIRO BLDG. FLOOR 5
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 952-967-5584
  • Fax: 651-293-8232
Mailing address:
  • Phone: 612-347-5871
  • Fax: 612-347-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberT-00522
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberT104047
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number82857
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57137
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number82857
License Number StateWI
# 6
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number57137
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: