Healthcare Provider Details

I. General information

NPI: 1831438936
Provider Name (Legal Business Name): WENGANG CAO SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12011 LEE JACKSON MEMORIAL HWY STE 501
FAIRFAX VA
22033
US

IV. Provider business mailing address

PO BOX 221135
CHANTILLY VA
20153-1135
US

V. Phone/Fax

Practice location:
  • Phone: 703-349-1379
  • Fax:
Mailing address:
  • Phone: 703-349-1379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number08-154
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: