Healthcare Provider Details

I. General information

NPI: 1275658734
Provider Name (Legal Business Name): GEORGE TIAN-YI WANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FAWCETT AVE SUITE 100
TACOMA WA
98402-1911
US

IV. Provider business mailing address

PO BOX 1535
TACOMA WA
98401-1535
US

V. Phone/Fax

Practice location:
  • Phone: 253-761-4200
  • Fax: 253-383-3553
Mailing address:
  • Phone: 253-761-4200
  • Fax: 253-383-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301083789
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number200800524
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60071506
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number4301083789
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: