=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285096552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA JUE WANG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2016
-----------------------------------------------------
Last Update Date | 01/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 DEER LN
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-413-5430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 DEER LN
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-413-5430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 299261
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------