Healthcare Provider Details

I. General information

NPI: 1891771457
Provider Name (Legal Business Name): WANLI CHENG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

PO BOX 20169
ROANOKE VA
24018-0506
US

V. Phone/Fax

Practice location:
  • Phone: 910-362-9511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number2007-00925
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2007-00925
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: