=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831355874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YAN WANG MEDICAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2008
-----------------------------------------------------
Last Update Date | 07/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4160 MAIN ST STE 217
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-3899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-7410
-----------------------------------------------------
Fax | 718-321-7510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4160 MAIN ST STE 217
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-3899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-7410
-----------------------------------------------------
Fax | 718-321-7510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MS. YAN WANG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-321-7410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 240681
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------