MEDICARE: JACQUELYN WANG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	15226TLG	CA
2	152W00000X	Optometrist	1124	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215319496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN WANG

Provider Business Mailing Address
First Line	:	8730 VICTORIA PARK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-5388
Country	:	US
Telephone Number	:	707-567-3508
Fax Number	:

Provider Business Practice Location Address
First Line	:	4175 S GRAND CANYON DR STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7155
Country	:	US
Telephone Number	:	702-912-4254
Fax Number	:	702-847-7624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	03/13/2025

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Directions to “ JACQUELYN WANG ” Practice Location

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