Provider Demographics
NPI:1003950494
Name:WANG, LAWRENCE PEI-WEN
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:PEI-WEN
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1834
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-0075
Mailing Address - Country:US
Mailing Address - Phone:425-687-7981
Mailing Address - Fax:
Practice Address - Street 1:16735 SE 272ND ST
Practice Address - Street 2:SUITE C
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4942
Practice Address - Country:US
Practice Address - Phone:253-639-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030690Medicaid
WAWA1418OtherREGENCE BLUE SHIELD
WAAB38325Medicare ID - Type Unspecified
WAU95910Medicare UPIN