MEDICARE: CAMILLE SIQI 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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1316797699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE SIQI WANG

Provider Business Mailing Address
First Line	:	1851 VIRGINIA RD
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2517
Country	:	US
Telephone Number	:	626-592-5852
Fax Number	:

Provider Business Practice Location Address
First Line	:	1851 VIRGINIA RD
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2517
Country	:	US
Telephone Number	:	626-592-5852
Fax Number	:

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

Provider Enumeration Date	:	03/27/2024
Last Update Date	:	03/27/2024

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