Healthcare Provider Details

I. General information

NPI: 1821351099
Provider Name (Legal Business Name): YUXUAN JERRY WANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 301
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

26520 CACTUS AVE. RCRMC GENERAL RESIDENCY RESIDENCY PROGRAM
MORENO VALLEY CA
92555
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-1854
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA131054
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD60862280
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD60862280
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: