=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619730520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTI-AGING AND WELLNESS MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2024
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11548 BELLAIRE BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77072-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-973-0024
-----------------------------------------------------
Fax | 281-973-0203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 COLE ST
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-5017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-973-0024
-----------------------------------------------------
Fax | 281-973-0203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JASON T WANG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-973-0024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------