Provider Demographics
NPI:1003966367
Name:WU, JIAN (PA)
Entity Type:Individual
Prefix:
First Name:JIAN
Middle Name:
Last Name:WU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:1250 JOHN B WHITE SR BLVD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3929
Practice Address - Country:US
Practice Address - Phone:864-574-0017
Practice Address - Fax:864-574-6088
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0003206363AS0400X
SC1643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC2563D267Medicare PIN