Provider Demographics
NPI:1023040839
Name:WANG, NAN (MD)
Entity Type:Individual
Prefix:
First Name:NAN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 SAN BERNARDINO RD
Mailing Address - Street 2:STE 102
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4912
Mailing Address - Country:US
Mailing Address - Phone:909-579-6721
Mailing Address - Fax:909-579-6737
Practice Address - Street 1:901 SAN BERNARDINO RD
Practice Address - Street 2:STE 102
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4912
Practice Address - Country:US
Practice Address - Phone:909-579-6721
Practice Address - Fax:909-579-6737
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55739208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G557390Medicaid
CADH124XMedicare PIN
E91894Medicare UPIN
00G557391Medicare ID - Type Unspecified