=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174356604
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QIANQIAN WANG NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2024
-----------------------------------------------------
Last Update Date | 08/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 588 NEW LOUDON RD
-----------------------------------------------------
City | LATHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12110-4057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-785-2662
-----------------------------------------------------
Fax | 518-786-6547
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 588 NEW LOUDON RD
-----------------------------------------------------
City | LATHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12110-4057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-785-2662
-----------------------------------------------------
Fax | 518-786-6547
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2918828
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------