Healthcare Provider Details

I. General information

NPI: 1649834375
Provider Name (Legal Business Name): LICHUN WANG PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PLEASANT ST
CONCORD NH
03301-7559
US

IV. Provider business mailing address

177 OLD WESTBORO RD
NORTH GRAFTON MA
01536-2013
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-2556
  • Fax:
Mailing address:
  • Phone: 508-839-5460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: