Healthcare Provider Details

I. General information

NPI: 1649850066
Provider Name (Legal Business Name): ANGIE YUEQI WAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W BLUEMOUND RD
WAUWATOSA WI
53226-4321
US

IV. Provider business mailing address

10000 W BLUEMOUND RD
WAUWATOSA WI
53226-4321
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5320
  • Fax: 414-805-5320
Mailing address:
  • Phone: 414-805-5320
  • Fax: 414-805-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number85242-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: