Provider Demographics
NPI:1003288572
Name:WAN, CLAIRE
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 MONTROSE ST # 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1212
Mailing Address - Country:US
Mailing Address - Phone:404-578-7843
Mailing Address - Fax:
Practice Address - Street 1:57 MONTROSE ST # 1
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1212
Practice Address - Country:US
Practice Address - Phone:404-578-7843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant